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U S DEPARTMENT OF 
HEALTH & HUMAN SERVICES 
Public Health Service 

Health Resources and Services Administrator! 
Bureau of Health Professions 
Division of Disadvantaged Assistance 

DHHS Publication No. (HRSA) HRS-P-DV 85-1 



Health Status 



of Minorities and 



Low Income Groups 





II • II 

• • II • • • 




Health Resources and 
Services Administration 

Robert Graham, M.D. 

Administrator 

John H. Kelso 
Deputy Administrator 

Bureau of Health Professions 
Thomas D. Hatch 
Director 

William A. Robinson, M.D. 
Deputy Director 

Division of Disadvantaged 
Assistance 

Clay E. Simpson, Jr., Ph.D. 

Director 

Arthur Testoff 
Deputy Director 

Kinzo Yamamoto, Ph.D. 
Chief 

Analysis and Evaluation 
Branch 



For sale by the Superintendent of Documents, U.S. Government Printing Office 
Washington, D.C. 20402 



Foreword 



One of the responsibilities of 
the Health Resources and 
Services Administration is to 
provide leadership with 
regard to issues of access, 
equity, and quality of health 
care for the Nation. 

In pursuit of this overall 
mission, we are proud to 
contribute this work toward 
greater understanding of the 
health status of minorities and 
persons with low income, for 
use by health professionals in 
addressing these important 
health issues. 

I would like to extend 
special thanks to Dr. Clay E. 
Simpson, Jr., Director, Divi- 
sion of Disadvantaged 
Assistance, and his staff for 
his leadership in focusing our 
attention on these issues. 



Thomas D. Hatch 
Director 

Bureau of Health Professions 




iii 



IV 



Table of Contents 



I. Introduction 3 

II. Vital Statistics 17 

III. Problems of Reproductive Health and Genetic Disease 47 

IV. Acute Disease Conditions 87 

V. Chronic Disease Condition 107 

VI. Trauma 137 

VII. Mental Health 155 

VIII. Dental Health 183 

IX. Preventive Health 205 

X. Utilization of Health Services 229 

XI. Financial Expenditures for Health Services 249 



Acknowledgements 



This second edition of 
Health Status of Minorities 
and Low-Income Groups was 
written by staff of the Centers 
for Health Education and 
Social Systems Studies 
(CHESS) under a contract 
with the Division of Disadvan- 
taged Assistance, Bureau of 
Health Professions. 

Assembling and analyzing 
the wide variety of data in- 
cluded in this book required 
the cooperation and 
assistance of many people. 
Within the Division, Dr. Kinzo 
Yamamoto had primary 
responsibility for directing 
and monitoring the project. I 
would like to thank him and 
his staff for the inestimable 
assistance he has provided 
throughout the period of the 
contract. 

Dr. Melvin H. Rudov, 
President of CHESS, directed 
the data collection and 
analysis, and the writing of 
the study. His principal staff 
were Jeanne A. Klingensmith 
and Nancy Santangelo. Ms. 
Margaret W. Pratt authored 
Chapter III, Problems of 
Reproductive Health and 
Disorders and, in turn, this 
chapter received critical 
review by Dr. Vince Hutchins 
and his staff of the Division of 
Material and Chief of Health, 
Bureau of Health Care 
Delivery and Assistance, 
Health Resources and Serv- 
ices Administration. Dr. 
Audrey Manley, Director, Of- 
fice of Clinical Affairs, also 
provided comments on this 
chapter. Mr. James L. Walker 
and Mr. Frank M. Harding 
were responsible for the 
graphics and technical ac- 
tivities related to publication. 



My thanks to these in- 
dividuals for this important 
effort. The content of this 
publication, however, does 
not necessarily reflect the 
views of the Federal Govern- 
ment nor does it incorporate 
all the comments and/or con- 
cerns of the reviewers. 

My deepest appreciation 
goes to Ms. Alice Haywood, 
Special Assistant for Com- 
munications, National Center 
for Health Statistics, who 
coordinated both the up- 
dating of data from the first 
edition and the first drafts of 
several of the chapters. 

Many others within 
CHESS, the National Center 
for Health Statistics, the Na- 
tional Institute of Mental 
Health, the Health Care 
Financing Administration, and 
other Federal agencies and 
private entities helped by pro- 
viding data, contributing 
editorial and factual com- 
ments, and correcting and 
sharing information. I wish to 
express my sincerest thanks 
to the authors, contributors 
and reviewers for their sus- 
tained industry and creative 
scholarship which has 
culminated in this work. 
Sincerely yours, 




Clay E. Simpson, Jr., Ph.D. 
Director 

Division of Disadvantaged 
Assistance 

Bureau of Health Professions 



2 



i 



Chapter I 



Introduction 



Table of Contents 



A. Purpose 5 

B. Methodology and Sources 5 

C. Definitional Issues 6 

1 . Disadvantaged 6 

2. Income 6 

3. Education Level 7 

4. Population Density 7 

5. Age 8 

6. Racial/Ethnic Minorities 8 

D. Interpretational Issues 9 

1. Interaction Between the Independent Variables 9 

2. Age Adjustment 10 

3. Revised Rates 10 

4. Concept of "the Disadvantaged" 10 

5. Health Status and Its Measurement 11 

6. Data Biases 11 
Tables 12 
References 16 

List of Tables 16 



4 




Chapter I 



Introduction 



A. Purpose 

The Division of Disadvan- 
taged Assistance (DDA), 
Bureau of Health Professions, 
Health Resources and Serv- 
ices Administration, has as its 
mission the initiation and con- 
duct of programs which pro- 
mote and assure equity in 
access to health resources. 
The Division administers the 
Health Careers Opportunity 
Grant Program (HCOP); com- 
piles, analyzes, and 
disseminates data on the 
health status of the disadvan- 
taged; and coordinates 
Special Presidential, Depart- 
mental, and other initiatives 
for enhancing health 
resources opportunities for 
the disadvantaged. The DDA 
has a constant need for 
sources of data which 
demonstrate the disparities 
that exist between the disad- 
vantaged and advantaged 
segments of our society, as 
well as information on the ef- 
fectiveness of programs 
aimed at reducing those 
disparities. 

The Office of Health 
Resources Opportunity 
(OHRO) was the predecessor 
organization to the DDA. 
When the various organiza- 
tions in the then Health 
Resources Administration in 
the mid-1 970's found that 
they were in need of large 
amounts of such data on a 
continuing basis, they asked 
OHRO to produce those data 
organized in a systematic 
manner. 

In 1977, a contract was let 
to Centers for Health, Educa- 
tion, and Social Systems 
Studies (CHESS) to produce 
the first and original edition of 
Health Status of Minorities 



and Low-Income Groups. 
That volume filled the need 
for an aggregation of data 
and an analysis of group dif- 
ferentials and trends. But that 
original work has now 
become outdated; most of its 
chapters included data no 
more recent than 1974. 

For this and other 
reasons, it was decided that 
a second edition of increased 
scope and greater definition 
was needed, one that would 
provide more recent data 
and more recent trend ef- 
fects. Thus, CHESS has pro- 
duced this second edition, 
appropriately revised and 
updated. 

It is impossible to an- 
ticipate all the ways in which 
a large pool of data, such as 
is provided in this report, 
may be used. Each of the 
segments of the government 
must make decisions on 
policy issues, conceptualize 
programmatic intervention 
programs, and evaluate pro- 
grammatic efforts. To do so, 
each must have data of the 
sort compiled here. Many 
people outside of govern- 
ment are involved in the 
delivery of health care serv- 
ices or in the analysis, 
evaluation, and research of 
the health care system. The 
educational community also 
needs reference and text 
works to assist in its 
pedagogical process. The 
CHESS staff, mindful of all 
these potential users, has 
tried to prepare a document 
that can be used by such a 
diverse audience and for an 
extremely diverse set of 
purposes. 

Many types of data, 
however, are very difficult to 
use in raw form. Social 
demographic data can lead 
to a wide variety of inter- 
pretations. Health system 



data are particularly difficult 
to construe without a com- 
prehensive understanding of 
all of the contributing factors. 
Because of these complex- 
ities, the CHESS staff has at- 
tempted, both through the 
selection of the data 
presented and through tex- 
tual interpretations of those 
data, to present some insight 
into what factors may be 
responsible for observed rela- 
tionships or differences be- 
tween comparison groups. 
These interpretations are 
especially necessary because 
it is beyond the scope of this 
report to present the in- 
dividual methodologies used 
for gathering the data for 
each of the studies cited. For 
sophisticated readers who 
wish to interpret the data 
themselves, this source book 
is meant as an initial 
reference work. Before these 
data are further used, the 
original data sources should 
be reviewed for an 
understanding of the data 
collection methodologies. 

B. Methodology and 
Sources 

One of the first tasks of the 
project to produce this sec- 
ond edition was for the con- 
tractor to meet with DDA staff 
members for the purpose of 
discussing (1) the contents of 
the second edition; (2) defini- 
tions of "the disadvantaged"; 
(3) coordination with other 
DDA projects; (4) access to 
data and data sources; and, 
most importantly, (5) any 
thoughts or constraints that 
would cause a redirection of 
the project. The consensus 
was that the project to pro- 
duce the second edition 
would be carried out in 



essentially the same fashion 
as the project for producing 
the original edition, including 
retaining the chapter topics 
and the general format of the 
chapters. 

The CHESS library was 
greatly expanded with new 
works on relevant topics, and 
then culled for documents 
containing information on 
each of the chapter topics. 
Extensive searches were also 
conducted in the National 
Library of Medicine; the 
libraries of the Graduate 
School of Public Health, the 
School of Medicine, and the 
general (Hillman) library at 
the University of Pittsburgh; 
and the Carnegie Library of 
Pittsburgh. The publication 
branches within several 
departments of the govern- 
ment were also combed for 
reference works. Discussions 
were held with a number of 
key individuals, governmental 
and nongovernmental, con- 
cerning both published and 
unpublished sources of data. 
In addition, letters soliciting 
information were sent to a 
select group of organizations. 
Probably the most significant 
omission from this work is the 
raw data contained in the 
data banks from which much 
of the included data were 
taken. Had it been readily 
available, a number of addi- 
tional, meaningful analyses 
could have been made on 
data disaggregated by the 
demographic variable of in- 
terest. Regrettably, it was 
beyond the scope of this 
project to have special data 
tabulations made on those 
raw data banks. 

In gathering information 
for the first edition, a large 
number of health-related 
organizations were solicited 
for data relevant to the 



5 



topics, subpopulations, 
specific diseases, health 
problems, medical services, 
etc., discussed in these 
chapters. Those organizations 
that responded with usable 
data were contacted again 
for information for inclusion in 
this second edition, as were 
some institutions that were 
brought to our attention 
through the literature or by 
knowledgeable personnel in 
the health arena. These 
organizations are listed below 
(including those that did not 
respond): 

Allegheny County Health 

Department 
American Academy of 

Optometry 
American Association of 

Bioanalysts 
American Board of Colon 

and Rectal Surgery 
American Board of Or- 
thopaedic Surgery, Inc. 
American Board of Physical 

Medicine and Rehabilitation 
American Board of Radiology 
American Board of Surgery, 

Inc. 

American Cancer Society- 
National Office 

American Cancer Society- 
Pittsburgh Office 

American Diabetes Associa- 
tion, Inc. 

American Heart 
Association— Western 
Chapter 

American Hospital 
Association 

American Medical 
Association 

American Medical Record 
Association 

American Podiatry 
Association 

American Speech and Hear- 
ing Association 

Baltimore City Health 
Department— Vital Statistics 



City and County of San 

Francisco— Department of 

Public Health 
College of Physicians & 

Surgeons of Columbia 

University— Center for 

Population and Family 

Health 
Institute for Social 

Research— The University of 

Michigan 
Inter-University Consortium 

for Political and Social 

Research 
John Wiley Publications 
Medical Care and Research 

Foundation 
Metropolitan Life Insurance 

Co. 

National Association for 
Retarded Citizens 

New York Medical College- 
Community & Preventive 
Medicine 

Rand Corporation 

Research Triangle Institute 

Sage Publications 

State of California- 
Department of Health 

State of New York- 
Department of Health 

SysteMetrics, Inc. 

The Ameiican Board of 
Neurological Surgery 

The American National Red 
Cross 

The Permanente Medical 
Group— Division of Preven- 
tive Medicine 
The Travelers Insurance 

Companies 
Tufts University, School of 

Nutrition 
Westview Press 

Where appropriate, rele- 
vant data that were received 
from these organizations 
have been included in the 
text. As the data came in, 
they were organized by topic 
and cross-referenced to other 
related or tangential topics. 



C. Definitional Issues 

A number of terms with 
which the CHESS staff had to 
deal have varying definitions 
depending on the usage. In 
this section, both the dif- 
ficulties in defining some of 
the more important of these 
terms and the definitions 
employed throughout the 
report will be explored. 
1. Disadvantaged 

Although there exists 
within our populace a series 
of groups that are disadvan- 
taged in a way that deserves 
our national attention, the 
concept of "the disadvan- 
taged" is itself quite vague. 
One of the reasons for this 
vagueness is that the groups 
comprising this cluster differ 
significantly from one another 
in quite a few respects, in- 
cluding how and why they 
are disadvantaged. It is un- 
necessary for us to try to ex- 
plain through sociological 
theory who is disadvantaged 
and why they are disadvan- 
taged. The important thing is 
that large amounts of data 
are available for describing 
health status, but much of it 
does not reflect social disad- 
vantagedness. To be 
pragmatic, it makes more 
sense for us to adopt defini- 
tions that can be supported 
by the data available. 

Generally, six variables 
have been used in the 
analyses throughout the 
book. These variables are in- 
come, education, sex, 
population density (in a few 
cases, geographical region), 
age, and membership in a 
racial/ethnic minority group. 
Not every variable is 
presented in all data sets. Ex- 
cept for sex, each variable 
presented certain complex- 
ities in its definition as well as 
in the interpretation of its ef- 
fect on the health status 



measurements of concern. In 
addition, differential age 
distributions within income 
levels, as well as differential 
distributions of both age and 
income within racial groups, 
act as confounding variables 
in comparisons between in- 
come groups and racial 
groups. Some of the caveats 
associated with data inter- 
pretation are explored further 
in the paragraphs below. 
2. Income 

We live in a socio- 
economic reality that requires 
people to purchase health 
care services. At our lower 
income levels, persons can- 
not afford health care serv- 
ices. The Medicaid program 
was initiated to provide some 
subsidies for these services 
to the people in the lower in- 
come brackets. This program 
has not eradicated medical 
indigency, however, since 
some medical services are 
not covered. Also, the family 
income requirements for par- 
ticipation in that program are 
such that a large number of 
people needing some sub- 
sidy cannot be beneficiaries 
of the program. 

Table 1 contains the 
percentage distribution of 
families by income for 1975 
and 1980. Both years are in- 
cluded to allow the reader to 
evaluate changes and lack of 
changes between those two 
years. To facilitate this com- 
parison, income level is in 
constant 1981 dollars. The 
table uses the income 
categories commonly found 
in health status data, with 
family income separated into 
eight groups. Median income 
dollars are also included. For 
1980, Spanish origin 
(Hispanics) is included as a 



6 



separate ethnic grouping. 
Rough comparisons can be 
made, however, between the 
1975 and 1980 data, since 
Hispanics are predominantly 
white. (Although the footnote 
to that table states that per- 
sons of Spanish origin can 
be of any race, the races of 
Spanish origin are usually 
identified as 95 percent 
white, 3 percent black, and 
2 percent other). 

Tables 2, 3, and 4 contain 
some disaggregations of the 
poverty population. From 
these tables it can be seen 
that a far greater proportion 
of blacks and Hispanics are 
clustered below poverty 
levels than (a) whites, (b) 
those classed as unrelated in- 
dividuals, and (c) those living 
in nonmetropolitan areas. 

Table 3 reports the status 
of the elderly with respect to 
the poverty level in both 
1975 and 1980. In these 
years, more than 15 percent 
of those aged 65 and above 
were indigent, according to 
the Census Bureau's poverty 
level definition. Within this 
table, some subgroups of 
those over 65 have a par- 
ticularly large percentage of 
persons financially distressed 
within their population: 
blacks, Hispanics, and those 
classed as unrelated 
individuals. 

One bias in these data 
comes from those who are in 
a transient low income state: 
those persons who desire 
employment but are tem- 
porarily unemployed, and 
students. Since neither of 
these groups necessarily 
shares medical indigency 
conditions with others in their 
income brackets, some 
distortion of the data results. 



3. Education Level 

Although the lore of our 
country is replete with 
Horatio Alger stories, it is true 
that there is a reasonably 
strong correlation between 
educational attainment and 
advantagedness. Some of the 
advantagedness that can af- 
fect health status is composed 
of three elements: the income 
to purchase health care serv- 
ices, the knowledge of which 
services to purchase, and the 
knowledge of how to use the 
services. 

Table 5 contains a 
distribution of the nation's 
adult population by educa- 
tional attainment. A large 
component of the population 
who have not completed at 
least an eighth grade educa- 
tion consists of the elderly, 
for whom such education 
was not common, and for 
whom education and income 
were not necessarily cor- 
related during their earlier 
life. Much of this is changing, 
however, as that large early- 
century mass of immigrants is 
dying off. In Table 5, note 
the dramatic changes be- 
tween 1960 and 1980 in the 
proportion of the population 
completing only an eighth 
grade education (17.5 per- 
cent in 1960, decreasing to 
13.4 in 1970, and further 
decreasing to 8.2 percent in 
1980). Even though we as a 
nation rank high in terms of 
the levels of educational at- 
tainment achieved by our 
populace, there remains a 
distinct difference in the 
health status of those at the 
various educational levels. 

4. Population Density 
Whenever the issue of in- 
sufficient health care 
resources has been raised, 
the response is usually that 
our country has sufficient 



resources, but that those 
resources are poorly dis- 
persed geographically. 
Health care personnel and 
health care facilities are con- 
centrated in those areas with 
the greatest population den- 
sities. Thus, this places some 
people at a disadvantage: 
those who, sufficient in in- 
come and educational level, 
happen to reside in an area 
of limited resources. 

The problems in dealing 
with the definitions of popula- 
tion density have been aptly 
described in an American 
Hospital Association publica- 
tion as guoted below, with in- 
formation updated where 
necessary. The author's 
changes or additions are in- 
dicated by brackets. 
It is difficult to draw a 
precise line separating 
metropolitan and 
nonmetropolitan regions, 
inasmuch as metropolitan 
areas can be defined not 
only by the number of 
residents, but also by the 
density of population and 
the proximity, accessibility, 
and even urban character 
of the facilities. The U.S. 
Bureau of the Census 
employs three different 
classification methods for 
describing the distribution 
of the population: 
metropolitan- 
nonmetropolitan, urban- 
rural, and farm-nonfarm. 
The development and 
usage of these terms are 
discussed below. 
Metropolitan- 
nonmetropolitan is the 
classification most fre- 
quently used in the tables 
[throughout the chapters 
of this book]. 



Metropolitan- 
Nonmetropolitan 

This classification is based 
on the definition of Stand- 
ard Metropolitan Statistical 
Areas (SMSAs) adopted 
by the U.S. Office of 
Management and Budget 
in 1980. They issue 
amendments to update 
this information when 
changes to SMSAs defini- 
tions are made. Except in 
New England, an SMSA 
consists of a county con- 
taining at least one city of 
50,000 inhabitants and 
any contiguous counties 
that are determined to be 
metropolitan in character 
and socially and 
economically integrated 
with the central city. [An 
urbanized area of at least 
50,000 inhabitants], when 
densely settled, con- 
tiguous places included, 
may also serve as the 
basis for an SMSA, pro- 
vided that the county or 
counties in which the city 
is located has a total 
population of at least 
[100,000], In New 
England, SMSA designa- 
tions are based upon 
cities and towns rather 
than counties. As of [June 
30, 1981, 323] SMSAs 
had been officially 
designated by the Office 
of Management and 
Budget. In the tables 
[presented in the following 
chapters], the category 
'Metropolitan' always 
refers to the areas 
designated as SMSAs, 
and 'Nonmetropolitan' 
represents all other areas. 
Although all the major 
metropolitan regions of the 
United States and many 
other cities and large 
towns are not included in 
SMSAs, Standard 
Metropolitan Statistical 



7 



Areas neither include all of 
the country's urban 
population nor exclude all 
of the rural and farm 
population. The use of 
counties as the basis for 
SMSAs is advantageous in 
the collection of statistics, 
but diminishes the ac- 
curacy of the distinction 
between urban and nonur- 
ban areas. [According to 
the 1980 census definition, 
the urban population com- 
prises all persons living in 
(a) places of 2,500 or 
more inhabitants incor- 
porated as cities, villages, 
boroughs (except in 
Alaska and New York), 
and towns (except in the 
New England states, New 
York, and Wisconsin), but 
excluding those persons 
living in the rural portions 
of extended cities (places 
with low population densi- 
ty in one or more large 
parts of their area); (b) 
census designated places 
(previously termed unin- 
corporated) of 2,500 or 
more inhabitants; and (c) 
other territory, incor- 
porated or unincorporated, 
included in urbanized 
areas. An urbanized area 
consists of a central city or 
a central core, together 
with contiguous closely 
settled territory that com- 
bined have a total popula- 
tion of at least 50,000. In 
all definitions, the popula- 
tion not classified as urban 
constitutes the rural 
population (2, p. 3)]. 
Farm-Nonfarm 
In order to provide infor- 
mation on the farm 
population of the United 
States, the Bureau of the 



Census also makes a 
distinction between farm 
and nonfarm residence. 
The farm population con- 
sists of all persons living 
on farms in rural areas. 
This includes all land on 
which agricultural opera- 
tions are conducted from 
which $1,000 or more of 
agricultural products were, 
or potentially could be, 
sold during the year (2, p. 
648). By this definition, in 
1980, only 2.7 percent of 
all Americans lived on 
farms. Since the farm 
population is often a 
group of special interest 
when persons living out- 
side metropolitan areas 
are being considered, in- 
formation available on the 
nonmetropolitan popula- 
tion frequently is divided 
between persons living on 
farms and persons living 
in other nonmetropolitan 
areas. (3, p. 6) 
"Substantial variation ex- 
ists in the availability of health 
resources among 
[nonmetropolitan-semirural 
areas, nonmetropolitan-rural 
areas, and metropolitan 
areas]. In 1977 (the midpoint 
of the period covered by 
National Health Interview 
Survey data), the number of 
patient care physicians per 
100,000 population ranged 
from 170 in metropolitan 
areas to 99 in semirural 
areas to 56 in rural areas. 
The variation in availability of 
board certified specialists was 
even greater. Much less 
variation existed in hospital 
beds per 1,000 
population— 5.0 in 
metropolitan and semirural 
areas and 4.1 in rural areas, 
according to 1976 data. 

"The characteristics of 
physician practices also differ 
between metropolitan and 



nonmetropolitan areas. 
Results from two different 
surveys of physicians con- 
ducted in 1975 show that 
physicians practicing in 
nonmetropolitan areas 
worked longer hours and 
saw considerably more pa- 
tients per week than those in 
metropolitan areas. Other dif- 
ferences between 
metropolitan and 
nonmetropolitan physicians 
are complex with no clear-cut 
implications in terms of ac- 
cess to care (Bureau of 
Health Manpower, 1980)." 
(4, p. 55) 
5. Age 

Statistics on the age 
distribution and 
characteristics of the U.S. 
population need to be ex- 
amined as they relate to 
other characteristics within 
the health care system. For 
the tables and figures 
presented throughout this 
book, age-adjusted data were 
used where possible to 
eliminate the bias associated 
with age distribution factors. 
Population subgroups of par- 
ticular interest are the very 
young and the elderly. Both 
of these groups place a high 
demand on the health 
system, although usually for 
entirely different reasons: the 
very young for prevention, 
the elderly for curative, 
palliative, and restorative 
medical services. Table 6 
presents a percentage 
breakdown of the 1970 and 
1980 total population accord- 
ing to age groups com- 
parable to those used within 
most of the tables and 
figures in this book. 

The elderly (those 65 and 
over) comprised 9.8 percent 
of the total population in 



1970, increasing to 11.3 per- 
cent in 1980. This group will 
continue to grow in size, 
making it important to ex- 
plore the less expensive and 
more available alternatives for 
caring for the aged. Those 
under 5 years of age made 
up 8.4 percent of the popula- 
tion in 1970 and 7.2 percent 
in 1980. This age group will 
increase for a time due to the 
large number of women who 
will be in their childbearing 
years for the next decade. 
The projection is, however, 
that by the year 2000 the 
rate of natural increase will 
reach an historic low. Thus 
this young age group, unlike 
the elderly age group, will 
begin to show a significant 
decrease in size. 

Racial minorities are not 
age distributed in the same 
proportions as are whites. In 
1980, 50 percent more of the 
white population was in the 
65-and-over age group than 
there were in the black 
population, and over 100 
percent more than in the 
American Native and 
Hispanic populations. Blacks, 
Hispanics, and the American 
Native group have a younger 
age distribution than whites. 
The younger age distributions 
of these minorities place 
them at a lower risk of the 
severe and debilitating mor- 
bidity associated with ad- 
vanced age. 

6. Racial/Ethnic Minorities 

This is one of the more 
difficult demographic 
categories with which to deal, 
since there is no simple 
scheme for classifying the 
category's subgroups. For 
the purpose of discussion in 
this book, racial minorities are 
defined as black Americans, 
Hispanics, Native Americans, 
and persons whose origins 



8 



are the Pacific Islands and 
Asia. Most of the health 
status data that are available 
are disaggregated by racial 
minorities into white and non- 
white subgroups. All of the 
above minorities are normally 
included in nonwhite 
subgroups. Such clustering 
can lead to significant 
misperceptions, for the follow- 
ing reasons, (a) American 
blacks dominate the numbers 
in the nonwhite group. In 
1981, 13.8 percent of the 
population was nonwhite; 
blacks made up 11.7 percent 
of the population, making 
them at that time the largest 
racial minority group in the 
United States, (b) The term 
"Native American" includes 
those frequently referred to 
as American Indians, 
Eskimos, and Aleuts from 
Alaska and neighboring 
islands. The American In- 
dians are comprised of ex- 
tremely diverse subgroups, 
some of whom are more like 
non-Indians in their mode of 
life than they are like each 
other. American Indians, of 
course, have very dissimilar 
backgrounds and ways of life 
from the Eskimos and Aleuts, 
(c) Similarly, the people 
grouped together as the Asia/ 
Pacific minority group are ex- 
tremely different from each 
other. Because of their small 
numbers, separate statistics 
on them are infrequently 
available. 

Of the ethnic minorities, 
the largest group by far is 
that referred to as Spanish 
American or Hispanics. This 
group, constituting approx- 
imately 6.4 percent of the 
1980 U.S. population, can be 



further divided into 
subgroups based on country 
of origin. This group includes 
whites, nonwhites of black 
and Indian origins, and many 
people of mixed racial 
parentage. The only things 
that the subgroups have in 
common are that (a) they 
come from countries that 
were once under Spanish 
dominion, and (b) most of 
them are still Spanish speak- 
ing (first or second 
language). The largest 
subgroup of this cluster is the 
Mexican Americans; Puerto 
Ricans and Cubans represent 
the second and third largest 
subgroups. The Mexican 
Americans congregate mostly 
in the agricultural and urban 
areas of the Southwest, the 
Puerto Ricans in the large 
cities of the North (particularly 
in New York City), and the 
Cubans in southern Florida. 

In writing about these 
groups, certain difficulties 
arise in trying to be both 
definitive and concise. For 
example, we have come 
across data that are disag- 
gregated by white and "All 
Other Races"; the "All Other 
Races" category was further 
subdivided into black and 
"All Others." We have found 
it necessary to coin terms not 
usually used in demography 
so that the reader can com- 
prehend the subgroups 
under consideration. We 
have used, therefore, the 
prefix "non" to refer to com- 
parison groups because of its 
perceptual simplicity. Just as 
other authors have used 
"nonpoor" to refer to those 
who are not in the poor 
group, but all of whom are 
not "rich," we have referred 
to the nonwhites, nonblacks, 



non-Indians, and non- 
Hispanics when comparing 
them to the whites, blacks, 
Indians, and Hispanics, 
respectively, because we 
believe that type of taxonomy 
will help our readers follow 
the discussions. 

Any attempts to improve 
the health of the nation, as 
well as the health of the 
disadvantaged, would be 
aided if those who generate 
health data could provide 
racial/ethnic breakdowns. The 
National Center for Health 
Statistics publishes the vast 
majority of health measures 
by racial categories. Some of 
the organizations that publish 
important data that are not 
disaggregated by any 
racial/ethnic distributions are 
(a) the National Safety Coun- 
cil in its annual publication, 
Accident Facts, (b) the 
Center for Disease Control in 
its annual publication, 
Sexually Transmitted 
Diseases, and (c) the Depart- 
ment of Labor in any of its 
publications data pertaining 
to accidents and injuries. Ac- 
cidents and sexually trans- 
mitted diseases are major 
causes of morbidity and 
mortality. The data published 
by these organizations are 
substantial and useful. Their 
usefulness to both re- 
searchers and policymakers, 
however, would be greatly 
enhanced by the inclusion of 
racial/ethnic distributions. 

D. Interpretational Issues 

1. Interaction Between the 
Independent Variables 

As discussed above, there 
are some relationships be- 
tween the variables of in- 
terest. That is, a lesser pro- 
portion of the elderly group is 



composed of blacks, and a 
larger proportion of the 
female group is composed of 
the elderly. There are other 
important relationships, and 
these are being reviewed 
below since they represent 
confoundings of the data to 
be presented. These con- 
foundings must be taken into 
consideration when inter- 
preting the data. 

(a) Members of racial and 
ethnic minorities tend to live 
in metropolitan areas. 

In 1980, 11.7 percent of 
the U.S. population was 
black, and 81.1 percent of 
the blacks lived in 
metropolitan areas. In the 
same year, 6.4 percent of the 
total U.S. population was of 
Spanish origin and 87.6 per- 
cent of them lived in 
metropolitan areas. These 
proportions may be com- 
pared to the 75.6 percent of 
the total population who lived 
in metropolitan areas in that 
"year. 

(b) Members of racial/ethnic 
minorities tend to be lower in- 
comed than the general 
population. 

Of the 1980 population 
classified by the U.S. Bureau 
of the Census as being 
below the poverty level, 32.5 
percent were black (com- 
pared with their 1 1 .7 percent 
proportion in the population), 
and 25.7 percent were of 
Spanish origin (compared 
with their 6.4 percent propor- 
tion in the population). 

(c) Members of the 
racial/ethnic minorities tend to 
be less educated than the 
general population. 

Table 5 depicts the educa- 
tional levels for whites, 
blacks, and Hispanics. As 
can be seen, whites in 1980 
differed from blacks by only 
0.5 in median school years 



9 



completed. There was a 1 .8 
median year spread, 
however, between whites and 
Hispanics. The distributions 
of educational attainment are 
negatively skewed for both of 
these minority groups. Note 
that in 1980, for example, 
those who had completed 7 
or less years of education 
comprised 8.0 percent of the 
white population, 20.3 per- 
cent of the black population, 
and 31 .8 percent of the 
Hispanic population. Thus 
these racial/ethnic groups are 
more heavily represented in 
the less educated group. 
Note also, however, that in 
the 20 years represented in 
Table 5, that the blacks have 
narrowed the educational 
gap, from a 2.9-year spread 
in I960 down to the 0.5-year 
spread in 1980. This narrow- 
ing represents a profound 
change in the educational 
level of blacks in its own 
right, but even more so 
because during those 20 
years white educational levels 
were themselves increasing 
by 1 .6 median years! 

In summary, the 
racial/ethnic minorities tend to 
live in metropolitan areas 
where health care resources 
are more plentiful. They do 
not have as many persons in 
the elderly group, where 
chronic illness and low in- 
come are more prevalent, as 
do whites. The racial/ethnic 
minorities are more poorly 
educated and have lower in- 
comes than whites. Where 
these socioeconomic factors 
affect health status, a dif- 
ferential in health status bet- 
ween them and their white 
counterparts can be 
expected. 

2. Age Adjustment 

Since prevalence rates, 
and particularly death rates, 
vary with age, it is important 



to consider the age distribu- 
tions of the groups that are 
being compared. Ideally, one 
would compare prevalence 
and death rates for each age 
group to remove the impact 
of age when comparing 
racial or other differences. In 
the case of a number of 
health status measures, 
published data do take into 
account the different age 
distributions of the com- 
parison groups by calculating 
age-adjusted rates. 

These age-adjusted rates 
remove any differences 
among racial/ethnic groups 
resulting from a difference in 
the age distribution of the 
various groups being com- 
pared. We have used age- 
adjusted data wherever 
possible. 

3. Revised Rates 

"The 1980 census 
enumerated approximately 
5.5 million persons more than 
previously estimated for 
April 1, 1980." (1, p. 27) 
Therefore, employing popula- 
tion estimates for 1971 
through 1979, birth and 
death rates needed to be 
revised to reflect new popula- 
tion estimates incorporating 
the results of the 1980 cen- 
sus. This revision of rates 
posed several serious pro- 
blems to the completion of 
this work. First, all analyses 
contained in this book de- 
pend on published data only. 
It is not always clear when 
each separate published 
source, even those sources 
generated by the National 
Center for Health Statistics 
(NCHS), began to published 
revised rates. Second, while 
revised crude death rates by 
cause of death began to ap- 
pear in the annual volumes 
of Vital Statistics of the 
United States beginning with 



data year 1976, revised, age- 
adjusted death rates by 
cause of death were not 
published in annual volumes, 
or anywhere else to the best 
of our knowledge. The age 
distribution of whites differs 
appreciably from the age 
distribution of the racial/ethnic 
groups included in the 
analyses of this book. To 
compare population-based 
rates of any group to whites, 
age-adjusted rates must be 
used to account for the age 
differences of the comparison 
groups. 

In the following chapters, 
trend tables containing in- 
tercensal year data generally 
are footnoted, indicating that 
the rates in the table have 
been revised. When it was 
not clear whether or not 
revised rates were used, or 
when it was certain that revis- 
ed rates were nor used (as is 
true for the vast majority of 
tables that employ population 
estimates), data from in- 
tercensal years were remov- 
ed. Since 1980 was the latest 
year for which published 
mortality data were available, 
this did not result in a 
sacrifice of more current 
data, nor did it deter us from 
comparing 1970 with 1980 
data. 

Indian Health Service data 
posed a special problem 
since the latest year for 
which data were available 
from this source was 1979. It 
was decided to include these 
trend tables rather than use 
1 970 as the latest data year 
or exclude this minority 
group entirely. 
4. The Concept of "the 

Disadvantaged" 

It would be preferable to 
compare affluent racial/ethnic 
minorities with affluent non- 



minorities, and racial/ethnic 
poor with nonminority poor to 
learn whether it is member- 
ship in the racial/ethnic 
minority or poverty that deter- 
mines differential health 
status, where such differen- 
tials exist. 

In most cases, the data do 
not exist in such a disag- 
gregated form. We are 
forced, then, to compare 
white with black and white 
with nonwhite in a number of 
comparisons, recognizing 
that advantaged blacks and 
other nonwhites as well as 
disadvantaged whites are in- 
cluded in the comparison. 
Differential income and 
education levels within the 
racial minority groups and 
among whites act as con- 
founding variables and 
further distort the racial com- 
parison. We can, however, 
predict the direction of these 
distortions. If the educational 
and income levels found 
among the disadvantaged 
groups were identical to or 
higher than those found 
among the advantaged 
groups, then any differentials 
would be attributable to 
group membership and not 
to income and education. 
The educational and income 
levels of the disadvantaged 
are, however, lower than 
those of the white com- 
parison group, and thus at 
least a component of the dif- 
ferentials should be at- 
tributable to such 
socioeconomic factors. In ad- 
dition, if trend data show a 
diminution of differentials at 
the same time that a diminu- 
tion in socioeconomic dif- 
ferences is shown, then addi- 
tional credence is given to 



10 



these socioeconomic factors 
as an important determinant 
of reduced health status. 
5. Health Status and Its 

Measurement 

The concept of health 
status involves two problems: 
to define health status, and to 
measure health status. There 
have been a number of at- 
tempts to deal with the 
former, but we are forced by 
exigencies to deal solely with 
the latter. 

Health status cannot be 
merely the absence of 
disease— rather, it is absence 
of disease accompanied by a 
feeling of well-being. It can- 
not be the relative incidence 
or prevalence of disease in 
any simple sense, since a 
large number of conditions 
that affect humans are 
subclinical. We are forced to 
hope that we each have 
some idea of what is meant 
by the concept of health 
status. Beyond such a loose 
approach to definition, we 
must have one additional 
common understanding of a 
concept of health status: it is 
multidimensional in nature 
and must be dealt with, 
measured, and interpreted 
multidimensionally. The health 
status of the disadvantaged, 
therefore, cannot be 
understood in terms of a 
single measurement, but 
must be conceived in terms 
of a profile. 

Even with this conceptual 
foundation, we cannot surge 
ahead measuring health 
status in all the ways possi- 
ble. We again are faced with 
the pragmatic problem of 
defining health status in 
terms of the data available 
rather than in terms of 
theoretically possible 
measurements. 



A final point about health 
status measurement: we are 
trying to conduct analyses of 
health status in the absence 
of a reasonable health status 
model. Given that health 
status is multidimensional and 
that it has to be measured as 
such, there is no conceptual 
framework for tying together 
the various dimensions. We 
cannot, of course, presume 
that there is no interaction 
between the dimensions. We 
can, for example, look at 
nutritional deficit as if it were 
an independent dimension, 
but we cannot be sure that if 
improvements in nutrition oc- 
curred, they would not be ac- 
companied by improvements 
along many of the other 
dimensions measured. In the 
absence of a model linking 
the various known health 
status dimensions, we have 
to realize that with multiple 
measures we may be 
measuring the same under- 
lying dimension duplicatively. 
6. Data Biases 

Much of the data reported 
and analyzed in the following 
chapters can be taken to be 
highly reliable. For example, 
the vital statistics and finan- 
cial expenditures data are 
based on tallies that probably 
are reliable, both in their 
methods of collection and in 
their actual measurement of 
what had occurred. The con- 
cern for 'potential biases in 
these types of data is 
whether the data are accom- 
panied by accurate 
sociodemographic measures 
of the people involved. 

Another set of data is 
based on self reports derived 
during interviews. Data 
derived from such a tech- 



nique may show bias for a 
number of reasons. For ex- 
ample, there is a possibility 
that the questions (a) were 
not understood, (b) were 
understood differently by the 
disadvantaged and the ad- 
vantaged populations, or (c) 
were answered by the 
respondents in a way that 
presented themselves more 
favorably, or less favorably, 
than was actually the case. 
Because of these factors, it is 
possible that the data are not 
valid. 

Finally, there are data 
based on physical examina- 
tions conducted by health 
care professionals. This 
technique should be one of 
the best sources of health 
status information. These 
surveys, however, require in- 
trusive examination pro- 
cedures which may introduce 
a bias. 

In summary, there are dif- 
ficulties in dividing the 
populace into advantaged 
and disadvantaged, obtaining 
health status data, and in in- 
terpreting the actual meaning 
of these data. In spite of all 
of these difficulties, the 
chapters that follow present a 
very consistent picture— one 
that allows us to make some 
reasonable conclusions. 



Table 1 

Money income of families— percent distribution by income level in constant (1981) dollars, by race 
and Spanish origin 1')/', am I 1 'J80 

Percent Distribution of Families, by Income Level 

Race of Total Median 
Householder fami- $50,000 Income 



and Year 


lies 
(1,000) 


Under 
$5,000 


$5,000- 
$9,999 


$10,000- 
$14,999 


$15,000- 
$19,999 


$20,000- 
$24,999 


$25,000- 
$34,999 


$35,000- 
$49,999 


and 
over 


(dol- 
lars) 


All Families 






















1975 


56,245 


4.5 


11.4 


12.7 


12.9 


13.2 


25.7 


11.5 


8.0 


23,183 


1980 


60,309 


5.6 


11.1 


12.7 


12.7 


12.7 


20.7 


15.4 


9.1 


23,204 


White 






















1975 


49,873 


3.6 


10.2 


12.3 


12.7 


13.6 


26.8 


12.2 


8.6 


24,110 


1980 


52,710 


4.5 


9.7 


12.3 


12.8 


13.0 


21.7 


16.2 


9.9 


24,176 


Black 






















1975 


5,586 


12.0 


22.3 


16.2 


14.6 


10.8 


17.5 


4.9 


1.7 


14,835 


1980 


6,317 


15.1 


22.0 


16.1 


12.5 


10.5 


12.9 


8.2 


2.7 


13,989 


Spanish 






















Origin 1 






















1975 


2,499 


9.1 


18.9 


18.4 


15.1 


12.7 


12.7 


16.9 


5.9 


16,140 


1980 


3.235 


10.4 


18.6 


17.5 


14.7 


11.7 


11.7 


15.3 


8.4 


16,242 



'Persons of Spanish origin may be of any race. 

Source: Compiled and abstracted by CHESS, U.S. Bureau of the Census, Current Population Reports, series P-60, No. 134, and 
earlier reports. In U.S. Bureau of the Census, Statistical Abstract of the United States: 1982-83 (103d edition). Table 713, 
p 432 Washington, DC, 1982. 



Tsibls 2 

Persons below poverty level and below 125 percent of poverty level: 1975 and 1980. 



Persons Below Poverty Level 



Number (mil) 



Percent of total population 



Persons 
Below 125 
Percent of 

Poverty 
Level 



Year Total 1 White 



Percent 

„, , Spanish T , . ...... , Spanish Number ,°. . 

Black " , „ Total White Black K . . „ , .„ total 

origin 2 (mil 



origin 2 



popu- 
lation 



Average 

Income 
Cutoffs for 
Non-Farm 
Family of 4 

At 125 
At percent 
poverty of 
level poverty 
level 



1975 25.9 17.8 7.5 3.0 12.3 9.7 31.3 26.9 37.2 17.6 5,500 6,875 

1980 29.3 19.7 8.6 3.5 13.0 10.2 32.5 25.7 40.7 18.1 8,414 10,518 

'Includes other races not shown separately. 
2 Persons of Spanish origin may be of any race. 

Source: Compiled and abstracted by CHESS, U.S. Bureau of the Census, Current Population Reports, series P-23, No. 26, 

and P-60. No 134, and earlier reports. In U S Bureau of the Census, Statistical Abstracts of the United States: 1982-83 
(103d edition). Table 727, p. 440. Washington, DC, 1982. 



12 



Table 3 

Selected characteristics of persons 65 years old and over below poverty level: 1975 and 1980. 

Number Below Poverty Level (1,000) Percent Below Poverty Level 



Characteristic 1975 1980 1 1975 1 1980 1 



Persons, 65 and over 2 .... 


3,317 


3,871 


15.3 


15.7 


White 


2,634 


3,042 


13.4 


13.6 


Black 


652 


783 


36.3 


38.1 


Spanish origin 3 


137 


179 


32.6 


30.8 


In families 


1,191 


1 ,423 


8.0 


8.5 


Householder 


728 


837 


8.9 


9.1 


Male 


585 


627 


8.3 


8.2 


Female 


143 


210 


12.7 


14.0 


Other members 


463 


586 


7.0 


7.8 


Unrelated individuals .... 


2,125 


2,448 


31.0 


30.6 


Male 


410 


408 


27.8 


24.4 


Female 


1,716 


2,039 


31.9 


32.3 


Persons 60 and over 


4,373 


4,929 


14.2 


14.1 



'Population controls based on 1980 census. 

beginning 1 979. includes members of unrelated subfamilies not shown separately. For earlier years, unrelated subfamily members 
are included in the "in families" category. 
3 Persons of Spanish origin may be of any race. 

Source: Compiled and abstracted by CHESS, U.S. Bureau of the Census, Current Population Reports, series P-60, No 133 In 
U.S. Bureau of the Census, Statistical Abstract of the United States. 1982-83 (103d edition.) Table 730, p. 442. Washington, DC, 1982. 



Table 4 

Money income of families— percent distribution by income level, by race and Spanish origin of 
householder, and selected characteristics: 1980. 



Race of Householder, Number 
Residence and of 

Educational families 

Attainment (1,000) 



Percent Distribution of Families, by Income Level 
($1 ,000) 



Under 
5.0 



5.0- 
9.9 



10.0- 
14.9 



15.0- 20.0- 
19.9 24.9 



25.0- 
29.9 



30.0- 
39.9 



40.0- 
49.9 



50.0 Median 
and income 
over (dol.) 



All families 1 


60,309 


6.2 


1 2.7 


14.2 


1 4.0 


13.7 


1 1 .2 


14.5 


6.8 


6.7 


21 ,023 


White 
























Total 


52,710 


4.9 


1 1 .3 


13.9 


14.1 


14.2 


11.8 


15.3 


7.3 


7.2 


21,904 


In metropolitan areas 


34,336 


4.3 


9.5 


12.2 


13.2 


14.0 


12.4 


17.0 


8.6 


8.9 


23,815 


In central cities 


11,826 


5.9 


11.8 


14.3 


14.4 


13.5 


11.3 


14.7 


6.9 


7.2 


21,293 


Outside central cities . 


22,510 


3.4 


8.3 


11.1 


12.5 


14.2 


12.9 


18.2 


9.5 


9.8 


25,138 


Outside metropolitan 
























areas 


18,374 


6.1 


14.7 


17.0 


15.9 


14.5 


10.7 


12.2 


4.8 


4.2 


18,794 


Householder completed 3 
























Elementary school: 
























Less than 8 years. . 


3,852 


13.0 


29.7 


22.3 


13.4 


7.9 


4.8 


5.9 


2.0 


1.0 


11,483 


8 years 


3,866 


7.2 


22.8 


22.2 


14.5 


12.3 


7.7 


8.8 


2.7 


1.8 


14,501 


High School: 
























1-3 years 


6,404 


7.2 


15.9 


19.0 


17.2 


13.5 


10.5 


10.7 


3.9 


2.2 


17,163 


4 years 


17,846 


3.7 


9.0 


13.4 


15.2 


16.9 


13.9 


16.6 


6.5 


4.8 


22,370 


College: 
























1-3 years 


7,488 


2.7 


6.2 


10.5 


13.6 


15.6 


13.5 


20.3 


9.9 


7.7 


25,470 


4 years or more . . . 


10,090 


1.2 


3.0 


5.2 


8.7 


11.5 


13.3 


21.6 


14.5 


21.0 


32,855 



Black 



Total 


6,317 


16.6 


23.8 


16.8 


12.8 


10.2 


6.7 


8.5 


3.0 


1.7 


12,674 


In metropolitan areas . . 


4,898 


15.6 


22.3 


15.8 


13.1 


10.7 


7.4 


9.5 


3.5 


2.1 


13,726 


In central cities 


3,545 


18.0 


22.8 


15.3 


13.7 


9.6 


7.4 


8.2 


3.1 


1.9 


12,865 


Outside central cities . 


1,353 


9.3 


21.1 


17.1 


11.6 


13.3 


7.5 


12.9 


4.5 


2.8 


16,242 


Outside metropolitan 
























areas 


1,419 


20.2 


28.7 


20.0 


11.8 


8.7 


4.2 


5.0 


1.2 


.3 


10,257 


Householder completed 3 
























Elementary school: 
























Less than 8 years . . 


1,039 


21.8 


36.6 


18.9 


8.6 


6.0 


4.2 


3.0 


.8 


.2 


8,599 


8 years 


386 


18.2 


35.2 


16.1 


10.9 


9.1 


3.6 


4.4 


1.8 


.5 


9,383 


High School: 
























1-3 years 


1,287 


19.4 


26.0 


17.1 


15.2 


9.6 


5.7 


4.7 


1.5 


.8 


11,331 


4 years 


1,835 


12.0 


19.5 


16.9 


14.4 


12.6 


8.3 


11.4 


3.8 


1.1 


15,504 


College: 
























1-3 years 


821 


7.8 


16.2 


18.4 


13.1 


11.2 


9.0 


15.3 


4.9 


4.1 


18,1 14 


4 years or more . . . 


406 


3.9 


8.1 


11.7 


11.0 


15.9 


12.2 


19.1 


9.3 


8.8 


24,830 


Spanish Origin 2 
























Total 


3,235 


11.5 


20.8 


18.7 


14.9 


11.3 


8.3 


9.0 


3.1 


2.5 


14,717 



'Includes other races not shown separately 

2 Persons of Spanish origin may be of any race. 

Restricted to families with householder 25 years old and over 

Source: Compiled and abstracted by CHESS. U.S. Bureau of the Census, Current Population Reports, series P-60, No. 132. In 
U.S. Bureau of the Census, Statistical Abstract of the United States. 1982-83 (103d edition). Table 715, p. 433. Washington, DC. 1982. 



14 



Table 5 

Years of school completed for persons 25 years old and over by sex, race, and Spanish origin: 
1960, 1970, 1980. 

Percent of Population Completing .. , 

- Median 

Year, Race, and Sex Elementary school High school College schoo . 

Population 0-4 5-7 8 1-3 4 1-3 4 years years 

(1,000) years years years years years years or more completed 

1960, all races . . 99,438 8.3 13.8 17.5 19.2 24.6 8.8 7.7 10.6 

White 89,581 6.7 12.8 18.1 19.3 25.8 9.3 8.1 10.9 

Male 43,259 7.4 13.7 18.7 18.9 22.2 9.1 10.3 10.7 

Female 46,322 6.0 11.9 17.8 19.6 29.2 9.5 6.0 11.2 

Black 9,054 23.8 24.2 12.9 19.0 12.9 4.1 3.1 8.0 

Male 4,240 28.3 23.9 12.3 17.3 11.3 4.1 2.8 7.7 

Female 4,814 19.8 24.5 13.4 20.5 14.3 4.1 3.3 8.6 

1970, all races . . 109,310 5.3 9.1 13.4 17.1 34.0 10.2 11.0 12.2 

White 98,112 4.2 8.3 13.6 16.5 35.2 10.7 11.6 12.2 

Male 46,606 4.5 8.8 13.9 15.6 30.9 11.3 15.0 12.2 

Female 51,506 3.9 7.8 13.4 1 7.3 39.0 10.1 8.6 12.2 

Black 10,089 15.1 16.7 11.2 23.3 23.4 6.9 4.5 9.9 

Male 4,619 18.6 16.0 11.1 21.9 22.2 6.7 4.6 9.6 

Female 5,470 12.1 17.3 11.3 24.5 24.4 6.0 4.4 10.2 

1980, all races 1 . 130,409 3.4 6.0 8.2 13.9 36.8 14.9 17.0 12.5 

White 114,763 2.6 5.4 8.3 13.1 37.6 15.1 17.8 12.5 

Male 54,389 2.7 5.5 8.3 12.5 33.1 15.8 22.1 12.6 

Female 60,374 2.5 5.3 8.4 13.7 41.6 14.5 14.0 12.5 

Black 12,927 9.2 11.1 7.2 21.3 30.8 12.5 7.9 12.0 

Male 5,717 11.4 10.6 7.1 19.9 29.8 13.5 7.7 12.0 

Female 7,209 7.4 11.5 7.4 22.4 31.5 11.7 8.1 12.0 

Spanish origins 5 934 15 8 16 0 8.7 14.9 26.7 10.2 7.7 10.7 

Male 2,825 16.5 15.4 8.5 14.8 24.0 11.8 9.2 10.9 

Female 3,109 15.3 16.7 8.9 15.0 29.2 8.7 6.2 10.6 

1 Population controls based on the 1980 census. 
2 Persons of Spanish origin may be of any race 

Source: Compiled and abstracted by CHESS, U S Bureau of the Census, U.S. Census of Population: 1960. vol. 1, and Current 
Population Reports, series P-20, No. 207, and unpublished data. In U.S. Bureau of the Census, Statistical Abstract of the United 
States: 1982-83 (103d edition). Table 226, p 143. Washington, DC, 1982. 



Table 6 

Percent distribution of the resident population, by age: 1970 and 1980. 

Year, 75 16 18 Me- 

sex, Total, Under years years years dian 

and all 5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-74 and 5-13 16-17 18-24 and and age 

race years years years years years years years years years years years years years years years over years years years over over (yr.) 

Per- 
cent 

1970 1 100.0 8.4 9.8 10.2 9.4 8.1 6.6 5.6 5.5 5.9 6.0 5.5 4.9 4.2 6.1 3.7 18.0 7.8 11.7 69.5 65.7 (x) 

198Q2 100.0 7.2 7.4 8.1 9.3 9.4 8.6 7.8 6.0 5.2 4.9 5.2 5.1 4.5 6.9 4.4 (NA) (NA) (NA) (NA) (NA) (x) 

In thousands, except as indicated. 1970 and 1980 data based on enumerated population as of April 1. Excludes Armed Forces overseas. 
NA = Not available. 
X = Not applicable. 

1 The 1970 resident population count is 203,302,031; the difference of 66,323 is due to errors found after tabulations were completed. 

2 The data shown for April 1. 1980 are consistent with the 7980 Census of Population and Housing, Advance Reports, PHC80-V total count of 226,505,825. 

Source: Compiled and abstracted by CHESS, U.S. Bureau of the Census, Census of Population: 1970, vol. 1. and Current Population Reports, series P-25, No. 717. In U.S. 

Bureau of the Census. Statistical Abstract of the United States: 1982-83 (103d edition). Table 31 . p. 27 Washington. DC, 1982. 



15 



References 

1 . National Center for Health 
Statistics: Annual Summary of 
births, deaths, marriages, 
and divorces: United States, 
1981. Monthly Vital Statistics 
Report, Vol. 30, No. 13. 
DHHS Pub. No. (PHS) 
83-1120. Public Health Serv- 
ice. Hyattsville, MD, 
December 1982. 

2. U.S. Bureau of the Cen- 
sus, Statistical Abstract of the 
United States: 1982-83 (103d 
edition). Washington, DC, 
1982. 

3. "Comparative Statistics on 
Health Facilities and 
Population-Metropolitan and 
Nonmetropolitan Areas," 
American Hospital Associa- 
tion, 1977. 

4. Kleinman, J.C., "Medical 
Care Use in Nonmetropolitan 
Areas" In Health United 
States, 1981. DHHS Publica- 
tion No. (PHS) 82-1232. 
Hyattsville, MD, December 
1981. 



List of Tables 

1 . Money income of 
families— percent distribution 
by income level in constant 
(1981) dollars, by race and 
Spanish origin: 1975 and 
1980. 

2. Persons below poverty 
level and below 125 percent 
of poverty level: 1975 and 
1980. 

3. Selected characteristics of 
persons 65 years old and 
over below poverty level: 
1975 and 1980. 

4. Money income of 
families— percent distribution 
by income level, by race and 
Spanish origin of 
householder, and selected 
characteristics: 1980. 

5. Years of school completed 
for persons 25 years old and 
over by sex, race, and 
Spanish origin: 1960, 1970, 
1980. 

6. Percent distribution of the 
resident population, by age: 
1970 and 1980. 



16 



Chapter II 



Vital Statistics: 

A First Look at Health Status 



Table of Contents 

Overview 19 

A. Introduction 19 

B. Population and 
Socioeconomic Characteristics 19 

C. Birth Rates and Fertility 21 

D. Mortality 23 

E. Life Expectancy 24 

F. Marriages and Divorces 26 
Tables 27 

References 46 
List of Tables 46 
List of Figures 46 



17 



18 



Chapter II 



Vital Statistics 



Overview 

Blacks are the largest 
minority group in the United 
States, making up 11.7 per- 
cent of the population in 
1980. Persons of Spanish 
origin (hereafter referred to 
as Hispanics), and Asian and 
Pacific Islanders, are the 
second and third largest 
minority groups, making up 
6.4 and 1.5 percent of the 
population respectively. The 
age distributions of selected 
minority subpopulations differ 
markedly from those of the 
remainder of the population. 
Roughly 60 percent of 
blacks, Hispanics, and 
American Natives are under 
30 years of age, compared 
with only 50 percent of the 
white population. Higher pro- 
portions of minorities fall 
below poverty level and have 
lower median incomes and 
lower educational levels than 
whites, with the exception of 
Asian and Pacific Islanders, 
whose median income and 
educational attainment are 
higher than those of whites. 

Birth rates for the U.S. 
population have increased 
since 1975, with whites ex- 
periencing a greater increase 
than nonwhites. Birth rates of 
minority groups are con- 
siderably higher than those of 
the population as a whole. 
The greatest ratio of minority 
to total population birth rates 
was that of American Natives 
(1.86 in 1978), followed by 
Hispanics, (1.43 in 1980) and 
blacks (1.39 in 1980). The 
higher fertility rates of blacks 
and Hispanics compared with 
whites suggest that their 
elevated birth rates are real 
and not a consequence of 



higher proportions of women 
of childbearing age. 

The proportion of blacks 
using contraception was 
found to be lower than the 
proportion of whites, and 
over twice the percentage of 
blacks have been reporting 
unwanted births than have 
whites in recent years. 

While nonwhites have ex- 
perienced considerably 
greater declines in mortality 
than have whites in the past 
10 years, they still experi- 
enced a mortality rate 37.5 
percent higher than that of 
whites in 1980, compared 
with a mortality rate 44.1 per- 
cent higher than that of 
whites in 1970. Nonwhite 
females have experienced 
the greatest decline in mor- 
tality in the past decade, and 
in most decades since the 
turn of the century. The mor- 
tality rates of American In- 
dians and Alaska Natives 
was 36.7 percent higher than 
that of whites in 1979. The 
mortality rate of all nonwhites 
was 37.8 percent higher than 
that of whites in 1970. 

With regard to disease- 
specific mortality, blacks have 
higher age-adjusted death 
rates for 13 of the 15 leading 
causes of death. The greatest 
differences between blacks 
and whites in absolute 
number of deaths per 
100,000 population were 
found for (a) diseases of the 
heart, (b) malignant 
neoplasms, and (c) homicide 
and legal intervention. 

Life expectancy was 
higher for whites (75.1 years) 
than for blacks (69.3 years) 
in 1982. Like the slight nar- 
rowing of the racial gap with 
respect to mortality, however, 
the ratio of black to white ex- 
pected life spans has also 
narrowed from 1.12 in 1970 
to 1.08 in 1982. 



Proportionately fewer non- 
whites are married and more 
are divorced compared with 
whites. While for each 
race/sex group the proportion 
who are married is decreas- 
ing and the proportion who 
are unmarried is increasing, 
these changes are occurring 
more rapidly among non- 
whites than among whites. 
One exception is the divorce 
rate among nonwhite males, 
which is changing less 
rapidly than divorce rates of 
other segments of the 
population. 

A. Introduction 

As a first look at the health 
status of the disadvantaged, 
this chapter forms the foun- 
dation for the discussion of 
other health problem areas 
covered in the following 
chapters. The material in this 
chapter represents the begin- 
ning of the process of 
answering the basic ques- 
tions of concern in this book: 
How do the disadvantaged 
differ from the rest of the 
population with regard to 
health status, utilization of the 
health care system, and ex- 
penditures for health care, at 
the present time and over 
time? and What factors ex- 
plain any of these 
differences? 

This chapter opens with a 
description of the 
demographic characteristics 
of the American population. 
The remainder of the chapter 
treats that subdivision of 
health statistics commonly 
referred to as vital statistics, 
which include births, deaths, 
marriages, and divorces. Vital 
statistics also serve as 
variables by which the health, 
growth, and movement of a 



population may be 
measured. 

Birth is associated with 
population growth and 
renewal, while death is 
usually associated with the 
most severe outcome of ill 
health. Marriages, in addition 
to their relationship to birth 
rates and to health, are in- 
dicators of economic trends. 
Births, deaths, and mar- 
riages, along with the related 
measures of fertility, life ex- 
pectancy, and divorce, are 
the basic measures used in 
this chapter to describe the 
health status of the disadvan- 
taged, relative to the re- 
mainder of the population. 

Chapter I of this book 
contains additional caveats in 
the interpretation of the data 
presented. In particular, the 
reader should note material 
pertaining to revised death 
rates. 

B. Population and 
Socioeconomic 
Characteristics 

This section presents popula- 
tion data in addition to age, 
sex, and income data con- 
cerning minority groups. 
"Population size, age and 
sex structure, socioeconomic 
composition, and other 
characteristics differentiate 
minority groups from the 
White population. Because 
these characteristics influence 
health, they must be con- 
sidered when assessing the 
health status of minority 
groups." (1 , p. 3) 

"In the 1980 census, 15 
groups were listed in the 
race item on the 1 980 ques- 
tionnaire: White, Black, 
American Indian, Eskimo, 
Aleut, Chinese, Filipino, 
Japanese, Asian Indian, 
Korean, Vietnamese, 



19 



Hawaiian, Samoan, Guama- 
nian, and Other." (2, p. 3) 
Before discussing the ethnic 
composition of the American 
population, we should point 
out the methods used in cen- 
sus procedures. All race 
categorization as well as the 
Spanish origin categorization 
(thereafter referred to as 
Hispanics) was based on self 
identification of respondents. 
In the 1980 census, among 
children of mixed racial 
parentage who were unable 
to choose a single race, the 
race of the mother was 
assigned during editing. This 
procedure was in contrast to 
that used in the 1970 census, 
wherein the race of the father 
was assigned, absent a self- 
selection. (2, p. 3) 

Blacks continue to be the 
largest minority group in the 
United States. In 1980, 
blacks numbered almost 26.5 
million, making up 11.7 per- 
cent of the total population 
(see Table 1). Percentages of 
the population falling into 
selected minority groups in 
1 980 based on data from 
Table 1 are listed below: 



Ethnic Group 

Blacks 

Hispanics 

Asians and Pacific 

Islanders 

American Indians 



The category "Hispanics" in- 
cludes persons of any race 
having origins in a Spanish- 
speaking country. This group 
is an ethnic rather than a 
racial group, however, since 
it is composed almost solely 
of persons who consider 
themselves white (95 percent 



white, 3 percent black, 2 per- 
cent other). (3, p. 9) 

Geographic location of 
minority groups is also 
presented in Table 1 . Over 
50 percent of all blacks live 
in the South. Higher concen- 
trations of almost all other 
racial groups are found in the 
west, as are Hispanics. The 
composition of States com- 
prising these regions is 
shown in Figure 1 . 

The age distributions of 
whites, blacks, American In- 
dians, and Hispanics are 
found in Tables 2, 3, and 4. 
In 1981, the median age of 
blacks was 6 years younger 
than that of whites (25.2 com- 
pared with 31.2 years). This 
difference, however, is 
becoming smaller over time. 
In both racial groups, an in- 
crease in median age occur- 
red between 1970 and 1981, 
with blacks experiencing a 
greater percentage increase 
(12.5 percent) than whites 
(8.0 percent). 

Even more so than blacks, 
Hispanics and the American 
Natives group (American In- 
dian and Alaskan Natives) 



Percent 

11.7 
6.4 

1.5 
.6 



have a younger age distribu- 
tion than have whites (see 
Tables 3 and 4). Combining 
age groups found in Tables 
2, 3, and 4, broad age group 
comparisons of minority 
groups with whites can be 
made. 



Age Whites 

Under 30(%) 48.0 

30-64 years(%) 40.0 

65 and over(%) 12.1 

Total % 100.1 



Note the concentration of 
the racial/ethnic subgroups in 
the youthful age brackets. 
Approximately one-sixth more 
of the American Native and 
Hispanic populations are 
under 30 than is the case for 
the white population, and ap- 
proximately one-ninth more of 
the black population falls into 
this age category. Fifty per- 
cent more of the white 
population is in the 65-and- 
over age group compared to 
the proportion of the black 
population in that age 
bracket, and over twice the 
proportion of whites are in 
that age bracket compared 
to the American Native and 
Hispanic populations. 

Regardless of the social 
and economic environment, 
blacks and Hispanics would 
tend to be poorer than whites 
by virtue of the relatively 
small proportions of their 
members in the most income- 
productive age group, 
namely 30 to 64 years. While 
40 percent of the white 
population falls into this age 
range, only 33 percent of 
blacks and 32 percent of 
Hispanics belong to this 
income-productive age 
group. On the other hand, 
the younger age distributions 
of blacks and Hispanics 
render them at lower risk of 
experiencing the high rates 
of morbidity that are 
associated with an older 
population. 





Am. 


His- 


Blacks 


Natives 


panics 


58.8 


63.9 


63.3 


33.4 


30.8 


31.9 


7.9 


5.2 


4.9 


100.1 


99.9 


100.1 



Economic level is another 
correlate of health status. For 
the most part, measures of 
health status are inversely 
related to income level 
measures. Many examples of 
this relationship are found 
throughout this book, with 
race serving as a measure of 
income level. In addition, the 
classic work by Kitagawa and 
Hauser on mortality differen- 
tials among socioeconomic 
levels illustrates this point 
using data from an earlier 
period of time (4). With 
regard to some diseases, 
however, morbidity and/or 
mortality increases with in- 
come level. Two examples of 
such exceptions to the 
general rule are incidence 
rates of breast cancer which 
are higher among women 
belonging to higher 
socioeconomic levels (5, 6) 
and suicide rates which are 
higher among whites than 
blacks (see Table 16). 

Social and economic 
characteristics of the popula- 
tion by race and Spanish 
origin are presented in Table 
5. The racial group with the 
highest median income in 
1979 was a minority group, 
namely Asians and Pacific 
Islanders with a median 
family income of $22,075, 
followed by whites ($20,840), 
Hispanics ($14,711), and 
blacks ($12,618). 

Looking at income level 
from another perspective, 14 
percent of the population was 



Population 

26,500,000 
14,600,000 

3,500,000 
1,400,000 



20 



Map of the U.S., Showing Census Divisions and Regions 



WEST 

Pacific 



Mountain 



WASHINGTON 



CALIFORNIA 



Pacific 



NEW MEXICO 



HAWAII 

Mountain 



NORTH CENTRAL 



West 

North Central 



NORTH DAKOTA 

MINNESOTA 



East 

North Central 



SOUTH DAKOTA 



WISCONSIN 



INDIANA 
ILLINOIS OHIO 



NORTHEAST 



Middle 
Atlantic 



New 
England 



NEW YORK 



WEST VIRGINIA 

VIRGINIA 

KENTUCKY 

NORTH CAROLINA 

TENNESEE 

SOUTH CAROLINA 



MAINE 

VERMONT NEW HAMPSHIRE 

MASSACHUSETTS 
RHODE ISLAND 
CONNECTICUT 
NEW JERSEY 
PENNSYLVANIA 



DELAWARE 
MARYLAND 



ARKANSAS 

MISSISSIPPI GEORGIA 
ALABAMA 

LOUISIANA 



West 

South Central 
SOUTH 



East 

South 

Central 



South 
Atlantic 



Source: U.S. Bureau of the Census. Taken from Statistical Abstract of the U.S.: 1982-83. 
U.S. Government Printing Office, Washington, DC, December 1982. 



designated below poverty 
level in 1981 (see Table 6). 
While 11.1 percent of the 
white population was 
classified as below poverty 
level, the proportion of the 
black population (34.2 per- 
cent) classified so was three 
times that of the whites. 

Educational levels are 
presented in Table 5. The 
relative position of racial 
groups when ranked by 
educational level is similar to 
their position when ranked by 
income level. Using the 
percentage of persons with 
one or more years of college 
completed to characterize the 
groups, Asians and Pacific 



Islanders ranked highest 
(50.1 percent), followed by 
whites (33.2 percent), blacks 
(21.8 percent), and Hispanics 
(19.4 percent). 

C. Birth Rates and Fertility 

Records of births are kept 
primarily to facilitate measure- 
ment of population growth 
and to plan services for dif- 
ferent age groups of popula- 
tions. Many factors of impor- 
tance to the future health 
status of the newborn and 
mother do not appear in birth 
records, however. Some of 
these factors are the dietary, 



rest, exercise, and alcohol 
and tobacco consumption 
practices of the mother dur- 
ing gestation. Factors sur- 
rounding birth, such as the 
age and condition of the 
mother, legitimacy, condition 
of the live birth, and levels 
and types of care received at 
the time of birth have long- 
range health implications. 
While some of these factors 
are discussed in Chapter III 
of this book, this chapter 
limits itself to trends in birth 
and fertility rates. 

In Table 7, the number of 
live births per 1,000 popula- 
tion are presented by race 
for selected years from 1940 



to 1980. The two main racial 
groupings found in Table 7 
are whites and all other races 
(nonwhites). Data pertaining 
to nonwhites are presented 
as a total for all other races 
combined and as a subtotal 
for blacks separately. The 
nonwhite birth rate was 51.0 
percent higher than that for 
whites in 1980 (22.5 for non- 
whites compared with 14.9 
for whites). In 1970, however, 
the nonwhite rate was 44.3 
percent higher than that for 
whites (25.1 for nonwhites 
compared with 17.4 for 
whites). The absolute dif- 
ference in birth rates between 
1970 and 1980 was only 
about 2 1 /2 points for each 
race group, however. 

The birth rate for the total 
U.S. population is on the in- 
crease, reaching 16.0 births 
per 1,000 population in 1982 
(7, p.1), the highest it has 
been since 1971 . 

While a decrease in birth 
rates occurred between 1970 
and 1980 for both whites and 
nonwhites (a 14.4 percent 
decrease for whites and 10.4 
percent decrease for non- 
whites), birth rates increased 
during the shorter period 
1975 to 1980 (a 9.6 percent 
increase for whites and a 7.1 
percent increase for 
nonwhites). 

Birth rate data for 
Hispanics have become 
available only recently. Infor- 
mation on births of Hispanic 
parentage, presented in 
Table 8, is based on 22 
States that include an item on 
their birth certificate on the 
ethnic or Hispanic origin of 
the mother and father 
(3, p. 1). These 22 States ac- 
counted for an estimated 90 
percent of all births of 
Hispanic origin in the United 



21 



States in 1980. Birth rates of 
Hispanics are considerably 
higher than white birth rates, 
are only slightly higher than 
the birth rates of blacks, and 
are lower than the birth rates 
of Indians and Alaska Natives 
(see Table 9). The number of 
babies born per 1 ,000 
population among Hispanics, 
among blacks, and among 
whites was 23.5, 22.9, and 
14.2, respectively, in 1980, 
while the birth rate of Indians 
and Alaska Natives was 28.4 
in 1978. 

A comparison of the birth 
rates of Indians and Alaska 
Natives with the total popula- 
tion over the past 10 years 
reveals very little change in 
the relative difference in birth 
rates of these two com- 
parison groups. The number 
of live births per 1 ,000 
population among Indians 
and Alaska Natives was 28.4 
in 1978 compared with a 
birth rate of 15.3 for the 
population as a whole, pro- 
ducing a ratio of 1.86 (see 
Table 9). A similar ratio of 
1.85 was observed in 1968, 
due to similar rates of 
decrease in birth rates for 
both comparison groups 
(about 12 percent). 

The birth rate is partly a 
function of the age distribu- 
tion of females in the popula- 
tion. For this reason, the fer- 
tility rate, which is the 
number of live births per 
1,000 women aged 15 to 44, 
is also used to describe the 
birthing experience of 
populations. From 1970 to 
1980, the U.S. fertility rate 
decreased 22.2 percent, from 
87.9 to 68.4 (see Table 7). 
The decrease among whites 
during this period was 23.1 
percent compared with 21.6 



percent among nonwhites. 
The fertility rate of nonwhites 
was 34.4 percent higher than 
that of whites in 1970, and 
36.9 percent higher than that 
of whites in 1980. 

A comparison can be 
made of birth rate and fertility 
rate differentials of Hispanics 
and other groups using data 
for the 22 States that report 
Hispanic origin on birth cer- 
tificates (see Tables 8 and 
10). Birth and fertility rates of 
specified minority groups for 
1980 are presented below, 
along with racial differentials 
expressed as ratios of 
minority birth or fertility rates 
to those of the total 
population. 



Tables 2 and 3) are 
presented below. 

Percent of 
Percent Females 
Females 15-44 

White 51.2 23.0 
Black 52.7 25.1 
Hispanic 50.2 24.6 

Both the black and the 
Hispanic populations are 
composed of slightly higher 
proportions of women of 
childbearing age than the 
white population which may 
account in part for their 
higher birth rates. Personal 
preferences, contraceptive 
practices, and cultural in- 
fluences may also contribute 



a) All origins 

b) White 
(non-Hispanic) 

c) Black 
(non-Hispanic) 

d) Hispanic 



Birth 
Rate 

16.4 
14.2 

22.9 

23.5 



Ratio to 
"All Origins" 
b/a, c/a, d/a 

.87 

1.40 

1.43 



Fertility 
Rate 

70.2 
62.4 

90.7 

95.4 



Ratio to 
"All Origins" 
b/a, c/a, d/a 

.89 

1.29 

1.36 



Since fertility rates of 
minorities are higher than 
those of whites, the higher 
birth rates of minorities can- 
not be explained solely by an 
excess of women of 
childbearing age among this 
group. The fact that fertility 
rate differentials are lower 
than birth rate differentials, 
however, suggests that a part 
of the birth rate excess of 
minorities is a function of 
greater numbers of women of 
childbearing age among 
minorities. Numbers of 
women and numbers of 
women of childbearing age 
(expressed as a percentage 
of the total population in 
each race or origin group) in 
1 980 (based on data from 



to the higher birth rates of 
these population groups. 

"The intrinsic rate of 
natural increase is the rate 
that would eventually prevail 
if a population were to ex- 
perience, at each year of age 
the birth rates and death 
rates occurring in the 
specified year and if those 
rates remained unchanged 
over a long period of time." 
(2, p. 60) In Table 11 intrinsic 
rates of natural increase are 
presented for 1940 to 1979 
by race. From 1960 to 1979 
the intrinsic rate of natural in- 
crease has declined for both 
racial groups, from 17.1 for 



whites and 27.7 for non- 
whites in 1960-1964 to -7.8 
for whites and 4.1 for non- 
whites in 1975-1979. 

Given the fertility rates and 
death rates of recent years, 
significant shifts in the racial 
composition of the population 
are to be expected. The 
direction of change in 
population composition has 
been, obviously, a decrease 
in the proportion of the white 
population and an increase in 
the proportion of racial 
minorities. The rate of natural 
increase among nonwhites, 
however, was lower in 1979 
(5.2) than in 1969 (15.4). The 
shift in racial proportions 
observed in the last few 
decades is, therefore, prob- 
ably slowing with respect to 
these two racial groups. 

The higher birth rates ex- 
perienced by racial minorities 
may be due to several fac- 
tors. One factor that should 
not be excluded from con- 
sideration is personal 
preference. Other factors with 
perhaps a stronger influence 
are related to the lower fre- 
quency with which minorities 
practice contraception, obtain 
abortions, or undergo 
sterilization. These practices 
may, in turn, be a result of 
greater financial barriers, less 
awareness of the availability 
of these services, less accep- 
tance of these practices, or 
less access to these services. 

Data from the National 
Survey of Family Growth in- 
dicate that blacks report, on 
an average, a much higher 
number of unwanted births 
than whites (see Table 12). 
While the percent of un- 
wanted births among both 
whites and blacks decreased 
from 1973 to 1976, blacks 
still report a percentage of 
unwanted births 2.7 times 



22 



that reported by whites in 
1976, 25.6 percent com- 
pared with 9.5 percent (see 
Table 12). The proportion of 
unwanted births is inversely 
related to education, and the 
rate is slightly lower among 
married mothers than it is 
among unmarried mothers. 
According to the National 
Fertility Survey, an increase 
in contraceptive use occurred 
between 1965 and 1973, fol- 
lowed by a slight decrease 
between 1973, and 1976 
(see Table 13). This was true 
for both white and black 
racial groups and for both 
age groups shown in Table 
13. The proportion of blacks 
using contraception remains 
lower than the proportion of 
whites (58.6 percent among 
blacks aged 15-44 years 
compared with 68.8 percent 
among whites of the same 
age). 

D. Mortality 

The transition from good 
health to ill health is often a 
gradual one, and to decide 
where one state ends and 
the other begins requires 
judgment. Because mortality 
is easy to ascertain, it has 
continued to be the most 
reliable single indicator of 
health conditions. Mortality 
statistics, however, have the 
limitation of being indicative 
of only a fraction of the mor- 
bidity in a population, and an 
in extremis fraction at that. 
Since death may occur in the 
absence of lengthy morbidity, 
and many disabilities of long 
duration do not result in 
death, morbidity and 
disability measures are used 
in addition to mortality 
measures to describe the 
health status of a population 
more fully. 



Although the death rate 
alone is not a comprehensive 
measure of health status, a 
decrease in the death rate 
provides one good tool for 
assessing overall im- 
provements in a population's 
health status. No matter how 
healthy a population may be, 
however, a large proportion 
of elderly persons will raise 
the death rate of that popula- 
tion. When comparisons of 
death rates over time or 
among subgroups are made, 
therefore, differences in the 
age distribution of the com- 
parison groups or periods 
must be taken into account. 
This is done by applying the 
age-specific death rates of a 
given year or subgroup to 
the age distribution of the 
population at one point in 
time, and is referred to as the 
direct method of age adjust- 
ment. All of the death rates 
discussed in this section are 
age adjusted to the 1940 
U.S. population. 

The greatest reductions in 
mortality rates in the United 
States occurred in the first 
half of the century. The age- 
adjusted mortality rate 
decreased from 17.8 deaths 
per 1,000 population in 1900 
to 8.4 in 1950 (see Table 14), 
a decrease of 52.8 percent 
over the 50-year period. Only 
a modest decrease (6.6 per- 
cent) in the age-adjusted 
death rate occurred in the 
1960's, followed by a large 
decrease (16.9 percent) in 
the 1970's (see Table 14). 

Presented below are 
calculations on the data in 
Table 14. The changes in 
age-adjusted death rates for 



four race/sex groups in the 
past two decades appear as 
percentages. 



1970-1980 
1960-1970 



For each of these four 
race/sex groups, greater 
declines in mortality were ex- 
perienced in 1970-1980 than 
in 1960-1970. Females con- 
sistently experienced greater 
drops in mortality than males, 
and nonwhites have ex- 
perienced greater drops in 
mortality than whites (except 
among males in 1960-1970). 
Despite the larger gains 
among nonwhites, they con- 
tinued to have a higher mor- 
tality rate than whites in 
1980. However, the mortality 
rate among nonwhites was 
37.5 percent higher than that 
of whites in 1980, compared 
with a mortality rate 44.1 per- 
cent higher in 1970. The 
greatest improvement during 
the 10-year period as well as 
during the 80 years since the 
turn of the century, has been 
among nonwhite females. 
The age-adjusted mortality 
rates of nonwhite females 
were almost as high as those 
of nonwhite males at the turn 
of the century. The rate for 
nonwhite females dropped 
below the rate for white 
males in the 1950's and was 
approaching the rate of white 
females in the 1970's (see 
Figure 2). 

Recent improvements in 
U.S. mortality rates, after a 
period of relative stability, 
have attracted attention. The 
decline is thought to be due 
primarily to reductions in 
heart disease and stroke (8, 
p. 24). Death rates from heart 



disease dropped dramatically 
in the 1970's, as did death 
rates from cerebrovascular 



Nonwhite 

Males Females 
-17.1 -24.7 
-1.7 -13.5 



disease and pneumonia (see 
Figure 3). Although death 
rates from some causes of 
death are increasing (see 
Figure 3), the impact on the 
total death rate of an in- 
crease in septicemia for ex- 
ample, is minimal compared 
with the impact of a decrease 
in death rates from heart 
disease. 

One of the racial minorities 
included in the nonwhite 
category is American Indians. 
Death rates of American In- 
dians are substantially higher 
than those for the total 
population. In 1979, the In- 
dian and Alaska Native mor- 
tality rate was 770.2 per 
100,000 population, com- 
pared with a rate of 588.8 for 
all races in the United States, 
yielding a mortality rate 31 
percent higher than that of 
the total population (see 
Table 15). 

A more thorough treat- 
ment of disease-specific mor- 
tality is found in those 
chapters later in this book 
that deal with specific disease 
conditions. This chapter 
briefly examines disease- 
specific mortality trends for 
the population and the 
relative impact on the disad- 
vantaged vis-a-vis leading 
causes of death. In Figure 3, 
age-adjusted death rates for 
13 of the 15 leading causes 
of death are shown from 
1950 to 1980. In reading 
Figure 3, note that the or- 



White 

Males Females 
-15.7 -18.0 
-3.3 -10.7 



23 



P5<gw® 2 

Age-adjusted mortality rates for Whites, by sex: 
U.S., 1935-1980 (deaths per 1,000 population) 



Male Female 

Calendar Years 



Deaths per 
1,000 Population 

1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 

20 



15 



10 



Age-adjusted mortality rates for Nonwhites, by sex: 
U.S., 1935-1980 (deaths per 1 ,000 population) 



Male Female 

Calendar Years 



Deaths per 
1,000 Population 

1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 

20 



15 



10 



Source: "Facts of Life and Death," National Center for Health Statistics, USDHEW, 
Rockville, MD, 1974, Table 24 p. 29. 1970, 1975, and 1980 data are taken from Table 14 
of this chapter. 



dinate is based on a 
logarithmic scale. 

Among the five leading 
causes of death, only one 
has increased appreciably 
since 1950: deaths from 
chronic obstructive 
pulmonary diseases. Death 
rates from heart disease, 
stroke, and accidents are 
decreasing, while death rates 
from cancer have increased 
only slightly in the last 30 
years. Among the 15 leading 
causes of death, age- 
adjusted death rates have in- 
creased most sharply for the 
following three diseases: 
chronic obstructive, 
pulmonary diseases (5th 
cause), homicide and legal 
intervention (11th cause), and 
septicemia (15th cause). 

The 15 leading causes of 
death in the United States in 
1980 are listed in Table 16, 
with sex and race ratios. 
Among the five leading 
causes of death, males have: 

1 . roughly three times the 
death rate of females for 
two of the causes (ac- 
cidents and chronic 
obstructive pulmonary 
disease); 

2. almost twice the rate of 
females for one of the 
causes (diseases of the 
heart); 

3. an over 50 percent 
higher rate than females 
for another of the causes 
(cancer); and 

4. a 20 percent higher 
rise than females for 
another cause 
(cerebrovascular disease). 

Considering all 15 leading 
causes of death, males have 
higher death rates than 
females for all of those 
causes, ranging from only 
2 percent higher (in the case 
of diabetes) to close to 400 
percent higher (in the case of 



homicide and legal interven- 
tion). The death rate from 
suicide is three and a third 
times higher; the death rate 
from accidents and chronic 
obstructive pulmonary 
disease is almost three times 
higher. 

Turning now to racial dif- 
ferences, blacks have higher 
age-adjusted death rates for 
13 of the 15 leading causes 
of death; their rates are lower 
than whites for chronic 
obstructive lung disease and 
suicide. They are almost six 
times more likely to die from 
homicide and legal interven- 
tion as are whites; three 
times more likely to die from 
nephritis, nephrotic syn- 
drome, and nephrosis; and 
almost three times more likely 
to die from septicemia. These 
three causes of death, 
however, represented only 
2.5 percent of all deaths that 



The ratio of one death rate 
to another provides a 
measure of the relative dif- 
ference between those two 
death rates; subtraction of 
death rates provides a 
measure of the absolute dif- 
ference. Among the 15 
leading causes of death in 
1980, those causes with the 
greatest absolute difference 
in number of deaths per 
100,000 population were: 

1 . diseases of the heart 
(blacks had 58.1 more 
deaths per 100,000 
population than whites); 

2. malignant neoplasms 
(blacks had 42.5 more 
deaths per 100,000 
population than whites); 
and 



3. homicide and legal in- 
tervention (blacks had 
33.7 more deaths per 
100,000 population than 
whites). 
The above calculations are 
based on age-adjusted death 
rates found in reference 9, 
pages 31-33. These three 
causes of death accounted 
for 60.3 percent of all deaths 
in the total population in 
1980 (see Table 1, Chapter 
V). 

E. Life Expectancy 

Life expectancy at birth in the 
United States in 1982 was 
74.5 years for the overall 
population (see Table 17). 
Disaggregating this statistic 
by race, however, life expec- 
tancy is observed to be 
higher for whites (75.1 years) 
than for nonwhites (70.9 
years) and blacks (69.3 
years). From 1970 to 1982, 



24 



Figure 3 

Age-adjusted death rates for 13 of the 15 leading causes of death: U.S., 1950-80 



Rate per 
100,000 

400 
350 
300 

250 
200 

150 

100 
90 
80 

70 
60 
50 

40 
35 
30 
25 

20 

15 

10 
9.0 
8.0 
7.0 
6.0 
5.0 
4.0 



3.0 — 



2.0 
1.5 

1.0 

0.9 
0.8 
0.7 
0.6 
0.5 
0.4 

0.3 
0.2 




0.1 



Revisions of the International Classification of Diseases 
Sixth Seventh Eighth 



Diseases of heart 



Ninth 



Chronic obstructive 
pulmonary diseases 
and allied conditions 





Septicemia 



Malignant neoplasms, 
including neoplasms 
of lymphatic and 
hematopoietic tissues 



Pneumonia and 
influenza 



Nephritis, nephrotic 
syndrome, and 
nephrosis 




whites experienced a 
3.4-year gain, compared with 
a higher gain of 5.6 years for 
nonwhites and 5.2 years for 
blacks. The white-to-black dif- 
ferential for life expectancy 
was 1.08 in 1982 compared 
with 1.12 in 1970. If this rate 
of convergence of life expec- 
tancy rates were to continue, 
then the racial difference 
would disappear before the 
year 2010. 

In 1982, women had a 
considerably longer life span 
than men (7.4 years longer). 
White women live 7.3 years 
longer than white men, while 
black women live 9.0 years 
longer than black men. The 
years of life gained between 
1970 and 1982 were highest 
for black females (5.5), 
followed by blacks males 
(4.8), white males (3.4), and 
white females (3.1). 

Before leaving the subject 
of life expectancy, mention 
should be made of a 
phenomenon referred to as 
the racial mortality crossover. 
Although this phenomenon 
deserves a fuller treatment 
than a work of this type 
allows, a brief discussion is 
worthy of inclusion. 
Researchers have observed 
lower life expectancy among 
nonwhites than among whites 
at lower age levels, followed 
by a reversal to higher life 
expectancy among nonwhites 
than among whites at ad- 
vanced ages. In his article 
addressing this issue, 
Markides (10) used life ex- 
pectancy data from 1978 
(see Table 18). He reported 
shorter life expectancy 
among nonwhite males than 
among white males until the 
age of 65, at which time non- 
white males have higher life 
expectancy than white males. 



1950 



1955 



1960 



1965 



1970 



1975 



1980 



Source: National Center for Health Statistics: Advance report, final mortality statistics, 
1980. Monthly Vital Statistics Report, Vol. 32, No. 4 Supp. DHHS Pub. No. (PHS) 83-1 1 20. 
Public Health Service, Hyattsville, MD, August, 1983. Figure 4, p. 5. 



25 



Among women the racial 
crossover occurs later. 

The reasons for this 
phenomenon are not known. 
The racial crossover 
phenomenon may involve dif- 
ferential early mortality, which 
selects out less robust per- 
sons from the disadvantaged 
population at relatively early 
ages so that at advanced 
ages the disadvantaged 
population has 
proportionately more robust 
persons (11). In addition, ac- 
cording to this theory, as 
minority mortality is reduced 
at early ages, the crossover 
will occur at later ages and 
eventually disappear. To see 
what has happened since 
1978, data from a recent life 
table (9, pp. 12-15) are 
presented below: 



F. Marriages and Divorces 

While both marriage and 
divorce rates have 
undergone change in recent 
decades, the change in 
divorce rates has attracted 
more attention. "The recent 
rapid rise in the American 
divorce rate, to heretofore un- 
precedented levels, must be 
counted among the major 
demographic changes occur- 
ring in the United States 
since World War II." (12, p. 1) 

Although marriage and 
divorce data are the proper 
domain of vital statistics, they 
are not direct measures of 
health status in the same way 
as are the other measures in- 
cluded in this chapter. Marital 
status influences the birth 
rate, is a risk factor in some 
disease conditions, and is an 



Years of Life Remaining 
Total 



All Other 



Age 

Interval 

65-70 

50-75 

75-80 

80-85 

85 and 
over 



Males 
14.2 
11.3 

8.8 
6.7 
5.0 



Females 
18.5 
14.8 
11.5 

8.6 

6.3 



Males 
13.5 
11.1 
8.9 
6.9 
5.3 



Females 
17.3 
14.2 
11.4 
9.0 
7.0 



Males 
12.9 
10.5 
8.3 
6.3 
4.5 



Females 
16.5 
13.4 
10.7 

8.2 

6.1 



If a mortality crossover 
does occur, it is at a later 
age, 80, than shown in the 
1978 data. Also, the 
crossover seems to occur in 
races other than white but 
does not occur among 
blacks. Explanations for this 
differential racial effect are 
highly speculative. The 
reader should also be aware 
that there has been some 
speculation that the crossover 
effect does not occur, and 
that the apparent 
phenomenon is a result of in- 
valid data. 



economic indicator. Divorce 
rates are also economic in- 
dicators and they are related 
to the health status of the 
population to the extent that 
the dissolution of family life 
may exert a negative in- 
fluence on the happiness and 
health of each family 
member. 

Of the four marital states, 
single, married, widowed, 



and divorced, the widowed 
proportion of the population 
(about 8 percent) has 
changed least from 1970 to 
1981 (see Table 19). The 
married percentage of the 
population changed from 
71.7 percent in 1970 to 64.9 
percent in 1981. While 20.5 
percent of the population was 
single in 1981, 16.2 percent 
of the population was single 
in 1970. While only 3.2 per- 
cent of the population was 
divorced in 1970, 6.7 percent 
was divorced in 1981. The 
population as a whole, then, 
has shifted to proportionately 
greater numbers of divorced 
persons, a lower proportion 
of married persons, and a 
higher proportion of single 
persons, while the proportion 
of widowed persons has re- 
mained relatively stable dur- 
ing the last 1 1 years. 

The distribution among 
marital states of blacks and 
Hispanics is presented in 
Table 20. Abstracting figures 
from Tables 19 and 20, a 
comparison of these two 
minority groups with the total 
population can be made for 
1980 and 1970. 



dissimilarities between these 
minority groups and the total 
population, however, are also 
seen: 

1. Appreciably higher pro- 
portions of blacks and 
Hispanics were single in 
the United States in 1980, 
compared with the total 
population. 

2. Hispanics display 
the greatest stability with 
regard to marital state dur- 
ing this 10-year period in 
two ways: proportionately 
fewer divorces and less 
change in the four marital 
states between 1970 and 
1980. 

3. A far higher propor- 
tion of widowed persons is 
found among blacks than 
among Hispanics or the 
total population. 

Since there are propor- 
tionately higher numbers of 
younger persons in these two 
minority groups than there 
are in the population as a 
whole, one would expect pro- 
portionately higher numbers 
of persons in the single state 
and lower numbers in the 
widowed state, other things 
being egual. This is true, with 





Total 


Black 


Hispanic 














Origin 






1970 


1980 


1970 


1980 


1970 


1980 


Single 


16.2 


20.1 


20.6 


30.5 


29.3 


30.8 


Married 


71.7 


65.7 


64.1 


51.4 


62.4 


59.8 


Widowed 


8.9 


8.0 


11.0 


9.8 


4.9 


4.0 


Divorced 


3.2 


6.2 


4.4 


8.4 


3.4 


5.3 



The marital status of these 
two minority groups is similar 
to that of the population as a 
whole in that the proportion 
of single and divorced per- 
sons has increased, the pro- 
portion of married persons 
has decreased, and the pro- 
portion of widowed persons 
has changed little in the past 
10 years. Striking 



the exception of the higher 
proportion of blacks in the 
widowed state, given the 
younger age distribution. In 
1980, 9.8 percent of blacks 
were widowed— 14.3 percent 
of black females and 
4.2 percent of black males 
(see Table 20), compared 
with 10.8 percent of females 
and, 2.0 percent of males in 
the total population (see 
Table 19). 



26 



Table 1 

Resident population by race and Spanish origin, by State: 1980. 

[In thousands. For composition of regions, see fig, 1] 



Region, Division, 








American 








Asian 






All other 


Spanish 


and State 


Total 


White 


Black 


Indian 1 


Chinese 


Filipino 


Japanese 


Indian 


Korean 


Vietnamese 


races 


origin 2 


U.S. 


226,546 


188,372 


26,495 


1,420.4 


806.0 


774.7 


701.0 


361.5 


354.6 


261.7 


6,999.2 


14 609 


Regions: 


























Northeast .... 


A Q IOC 

4y, 1 00 


A 9 QQR 


A ft/1 ft 
4,040 


7Q n 
/ y.u 


017 7 


7R 1 
/O.I 


AR Q 

4o.y 


1 on r 
I dU.o 


£r 9 


OA Q 

^4,y 


1 ftOQ n 


9 £n/i 


No. Central . . 


58,866 


52,195 


5,337 


248.4 


72.9 


80.0 


44.5 


85.2 


62.3 


36.7 


704.0 


1,277 


South 


75,372 


58,960 


14,048 


372.2 


90.6 


82.6 


44.7 


83.6 


70.4 


80.3 


1,539.9 


4.474 


West 


43,172 


34,890 


2,262 


720.7 


424.8 


537.0 


564.9 


72.0 


153.8 


120.0 


3,427.4 


6,254 


in. tng 


1 9 ft/lft 
I ^L,o4o 


I l ,Dou 


A7R 
4/0 


^1 1 .O 


n 

OO. u 


R R 
0.0 


7 R 


1 R R 

I 0.0 


O.O 


a 1 

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1 R7 9 
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9QQ 

^yy 


Maine 


1,125 


1,110 


3 


4.1 


.5 


.7 


.3 


.4 


.5 


.5 


4.8 


5 


N.H 


921 


910 


4 


1.4 


.8 


.3 


.4 


.6 


.5 


.2 


2.3 


6 


Vt 


511 


507 


1 


1 .0 


.3 


.1 


.2 


3 


.3 


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1.3 


3 


Mass 


5,737 


5,363 


221 


7.7 


25.0 


3.1 


4.5 


8.4 


4.7 


3.2 


96.4 


141 


R.I 


947 


897 


28 


2.9 


1 .7 


1 .2 


.5 


.9 


.6 


.3 


14,8 


20 


Conn 


3,108 


2,799 


217 


4.5 


4.7 


3.1 


1 .9 


5,0 


2.1 


1.8 


67.6 


124 


Mid Atl 


36.787 


30,741 


4,374 


57.4 


184.8 


66.6 


39.1 


105.2 


59.5 


18.8 


1,140.8 


2,305 


N.Y 


17,558 


13,961 


2,402 


39.6 


148.1 


34.0 


24.5 


60.5 


34.2 


6.6 


847.7 


1,659 


N.J 


7,365 


6,127 


925 


8.4 


23.4 


24.4 


9.9 


29.5 


12.8 


2.9 


201 .0 


492 


Pa 


11,864 


10,652 


1,047 


9.5 


13.3 


8.3 


4.7 


15.2 


12.5 


9.3 


92.1 


154 


t. no. uem 


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4.0 


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PftA 

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Mich 


9,262 


7,872 


1,199 


40.0 


11.0 


11,2 


5.9 


147 


8.7 


4.2 


95.1 


162 


Wis 


4,706 


4,443 


183 


29.5 


4.1 


2.7 


2.2 


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2.6 


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33.1 


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4,040 


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1 c;7n 

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1 /1QH 
1 ,4c?U 


Aft 
40 


Q 9 

y .c. 


1 1 


Q 

.y 


1 A 


Q 

.y 


1 n 


1 A 

I -4 


1^1 
I O. I 


9ft 
dO 


Kans 


0 ftfi/1 
Z,o04 


0 1 
I DO 


1 9£; 


1 0.4 


9 A 


1 7 


1 R 


9 a 


c.X> 


ft 7 


ftQ 

oy .0 


Rft 
DO 


So. Atl 


36,959 


28,659 


7,852 


118.7 


50.5 


56.5 


25.1 


46.2 


44,7 


28.5 


277.5 


1,194 




£Q/I 

oy4 


A QQ 

400 


QR 


1 P 


1 n 


Q 

.0 


A 

.4 


1 1 


.0 


9 


R ft 

O.o 


1 n 

i u 


KAri 


4,£ 1 / 


ft 1 

0, I oy 


yoo 


o.u 


1/1 c 


I I .u 


A ft 

4.0 


1 ft 7 


1C 1 

I O. I 


A 1 

4 | 


9fi ft 

do.o 


0 U 


u.o 


OoO 


I / d 


A AO 

44y 


1 n 


9 

^.0 


1 ft 
i .0 


0 

.0 


Q 

.y 


Q 
O 


C 

.0 


1 n ft 


1 ft 

I 0 


Wo 

va 


ft/i 7 
O,o4 / 




1 nno 
i ,uuy 


y.o 


Q / 

y.4 


1 ft Q 

i o.y 


R 9 


ft R 

0.0 


19 c 
I ic.0 


1 n n 


ft/i /i 

o4 , 4 


0 u 


W. Va 


1,950 


1,875 


65 


1.6 


.9 


1.3 


.4 


1.6 


.6 


.3 


3.2 


13 


N.C 


5,882 


4,458 


1,319 


64.7 


3.2 


2.5 


3.2 


4.7 


3.6 


2.4 


21.2 


57 


S.C 


3,122 


2,147 


949 


5.8 


1 .4 


3.7 


1 .4 


2.2 


1 .4 


1.1 


9.1 


33 


Ga 


5,463 


3,947 


1 ,465 


7.6 


4.3 


2.8 


3.4 


4.3 


6.0 


2.3 


20.1 


61 


Fla 


9,746 


8,185 


1,343 


19.3 


13.4 


14.2 


5.6 


9.1 


4.7 


7.6 


145.2 


858 


E. So Cent 


14,666 


11,702 


2,869 


22.5 


7.6 


5.7 


4.8 


8.6 


6.7 


5.1 


34.2 


120 


Ky 


3,661 


3,379 


259 


3.6 


1.3 


1,4 


1.1 


2.2 


2.1 


1.1 


9.4 


2^ 


Tenn 


4,591 


3,835 


726 


5,1 


2.9 


1 ,9 


1.7 


3.2 


2.2 


1 4 


1 1.3 


34 


Ala 


3,894 


2,873 


996 


7.6 


1 .5 


1 ,0 


1 .4 


2.0 


1 .8 


1 .3 


8.4 


33 


Miss 


2,521 


1,615 


887 


6.2 


1.8 


1.4 


.7 


1 .2 


6 


1 .3 


5 1 


25 


vv. 00. uent. . . . 


no 7/17 
£o, / 4 / 


-1 ft £0.0. 

1 o.oyy 


ft R07 


oq 1 n 


qo R 

Oct .O 


on ft 
duo 


1 A 7 
14/ 


OR R 


1 q n 
i y.u 


AP> 7 
4D. / 


1 99R 1 

I ,ddo. I 


ft 1 £n 
0, l ou 


ATK 




1 Don 


ft7/1 
0/4 


Q A 

y.4 


1 O 

I .0 


0 
y 


0 
.0 


0 
.0 


c 

0 


9 1 


D.o 


1 R 

c 


La 


/i one 


0 0.1 0 
z,y i ^ 


1 oqo 
I ,doo 


101 


0. 0 
0.0 


0 e 


I .0 


O O. 


1 7 

i . / 


1 n q 

i u.y 


on c; 


QQ 


UKia 


ft HOC 


£,030 


dUO 


1 oy .o 


0 c; 


-1 7 


0 n 


O Q 

^.y 


9 7 


A 7 
4. / 


97 n 
0 / .U 


^ ~ 


Tex 


14,229 


11,196 


1,710 


40.1 


25.5 


15.1 


10.5 


22.2 


14.0 


29.1 


1,164.1 


2,986 


MI 


1 1 0.70 
I 1,0/0 


y.ytn 


9£Q 

^oy 


OC/l /I 

OD4.4 


i y.o 


1 ft R 
I O.O 


97 n 


7 ft 

/ .0 


1 ft n 
l o.u 


111 
i i . i 


ooD.y 


1 /i /i ft 

1 ,44o 


Mont. ■. 


707 


7 AC\ 

/ 4U 


0 
d 


Q7 Q 

0 / .0 


q 
.0 


R 

.0 


0 
.0 


0 


0 
.0 


ft 

.0 


^ 9 


1 n 

l u 


Idaho 


OA A 

y44 


yUii 


ft 
0 


i u.o 


Q 

.y 


7 


9 £ 


Q 
.O 


.0 


A 
.4 


9ft R 
do.O 


37 
O 


vvyo 


/i 7n 
4 / U 


/I /I C 

44o 


0 
O 


/ . 1 


A 

.4 


0 
.0 


D 


O 
d 


.d 


.d 


1 n r 

1 U.O 


n 1 
^:4 


uoio 




d,D 1 \ 


1 no 
\ Ud 


1 cS. 1 


o.y 


O O. 


Q O. 

y.y 


O ft 


R ft 
O.O 


a n 
4.U 


1 7n a 
I /U.4 


ft/in 
o4U 


N. Mex. 


1,303 


978 


24 


106 1 


1 4 


1.2 


1.3 


.8 


.7 


1.0 


188.7 


477 


Ariz 


2,718 


2,241 


75 


152.7 


6.8 


3.3 


4.1 


2.1 


2.4 


1.9 


229.0 


441 


Utah 


1,461 


1,383 


9 


19.3 


2.7 


.9 


5.5 


.8 


1.3 


2.1 


36.6 


60 


Nev. ... r ... . 


800 


700 


51 


13.3 


3.0 


4.1 


2.3 


.6 


2.1 


1.1 


22.7 


54 


Pac 


31,800 


24,929 


1,993 


356.4 


405.3 


523.2 


538.0 


64.7 


140.9 


108.8 


2,740.5 


4,811 


Wash 


4,132 


3,779 


106 


60.8 


18.1 


24.4 


26.4 


4.0 


13.1 


9.8 


90.8 


120 


Oreg 


2,633 


2,491 


37 


27.3 


8.0 


4.3 


8.4 


1.9 


4.4 


5.6 


45.5 


66 


Calif 


23,668 


18,031 


1,819 


201.4 


322.3 


357.5 


261.8 


57.9 


103.8 


89.6 


2,423.4 


4.544 


Alaska 


402 


310 


14 


64.1 


.5 


3.1 


1.6 


.2 


1.5 


.4 


7.0 


10 


Hawaii 


965 


3 1 9 


1 7 


2.8 


56.3 


133.9 


239.7 


.6 


18.0 


3.5 


173.8 


- - 



includes Eskimo and Aleut. 



2 Persons of Spanish origin may be of any race. 

Source: U.S. Bureau of the Census, 1980 Census of Population. Vol. 1, chapter B. Taken from Statistical Abstract of the 
United States: 1982-83, U.S. Government Printing Office, Washington, DC, December 1982, Table 36. p. 32 



27 



Table 2 

Resident population, by age, sex, and race: 1970-1980. 

(In thousands, except as indicated. 1970 and 1980 data based on enumerated population as of April 1. Other years based on estimated population as of July 1. Excludes 
Armed Forces overseas ) 



Year, sex, and race 


Total all 
years 


Under 5 
years 


5-9 
years 


10-14 

years 


15-19 
years 


20-24 
years 


25-29 
years 


30-34 
years 


35-39 
years 


40-44 
years 


1970 total 1 2 


203 235 


17,163 


19 


969 


20,804 


19,084 


16,383 


13,486 


1 1 ,437 


11,113 


1 1 ,988 


Male 


98,926 


8,750 


10 


175 


10,598 


9,641 


7,925 


6,626 


5,599 


5,416 


5,823 


Female 


104,309 


8,413 


9 


794 


10,206 


9,443 


8,458 


6,859 


5,838 


5,697 


6,166 


White 


178 098 


14,464 


16 


941 


17,724 


16,412 


14,327 


1 1 ,850 


1 0,000 


9,749 


10,633 


Male 


86,906 


7,396 


8 


656 


9,056 


8,314 


6,966 


5,869 


4,942 


4,798 


5,207 


Female 


91,192 


7,068 


8 


285 


8,667 


8,098 


7,361 


5,980 


5,058 


4,951 


5,426 


Black 


22,581 


2,434 


2 


749 


2,812 


2,425 


1,816 


1,429 


1,254 


1,196 


1,199 


Male 


10,749 


1,220 


1 


0V0 


1,408 


1,203 


841 


658 


568 


541 


544 


Female 


1 1 R99 

II ,OOtL 


1 9 1 A 


1 


Q "7 1 


1 A C\A 


1 999 


y / o 


771 
/ / I 


boo 


ODD 


boo 


1980, total 1 3 


226,505 


16,344 


16 


697 


18,241 


21,162 


21,313 


19,518 


17,558 


13,963 


1 1 ,668 


Male 


110,032 


8,360 


Q 
O 


OOtS 


9,315 


10,752 


10,660 


9,703 


8,676 


6,860 


€,708 


Female 


1 1 P. A 79 
I I 0,H 1 o 




Q 
O 


1 co 

1 by 




1 n a 1 n 


1 n ceo 


y,o 1 4 


Q PH9 


7 1 HQ 


o,yb i 


White 4 


194,779 


13,425 


13 


725 


15,103 


17,686 


18,079 


16,668 


15,164 


12,126 


10,113 


Male 4 


94,960 


6,887 


"7 


038 


7,733 


9,010 


9,106 


8,369 


7,569 


6,016 


4,992 


Female 4 


QQ CM Q 

yy ,o i y 


D,Oo / 


r- 

b 


C O 1 

Do / 


i Q£;g 


Q C7c; 
0,D I D 


Q Q7Q 

o,y / o 


Q OQQ 

o,£iyy 


7 enc; 


b, \ I U 


P. 191 


Black 4 


26,624 


2,452 


2 


503 


2,687 


3,000 


2,741 


2,334 


1,899 


1,465 


1,258 


Male 4 


12,582 


1,236 


1 


OCT 

2b2 


1,351 


1,497 


1,309 


1,091 


876 


666 


569 


Female 4 


"1 A C\A O 
I4,U4£ 


1 OIK 
1 1 D 


H 
1 


O A 9 

242 


1 99fi 


I ,OUo 


1 ,4oo 


1 OA A 
I ,^44 


1 n9T 


oUU 


CQQ 

boo 


1981, total 


229,307 


16,939 


16 


045 


18,241 


20,378 


21,731 


20,067 


18,737 


14,407 


12,043 


Male 


111,423 


8,667 


8 


OA A 

204 


9,321 


10,363 


10,914 


9,995 


9,273 


7,087 


5,896 


Female 


117 QQA 
II/ ,004 


o,d 1 id. 


1 


O A H 

841 


Q QOI 

o,y^ i 


HA rue 
1 U,U ID 


1 n q 1 q 
1 U,ol o 


1 H H70 


y,4oo 




c: 1 A 7 
b, I 4 / 


White 4 


196,627 


13,799 


13 


153 


15,051 


16,956 


18,347 


17,073 


16,127 


12,489 


10,432 


Male 4 


95,877 


7,081 


r> 
D 




7,710 


8,642 


9,268 


8,584 


8,062 


6,205 


5,155 


Female 4 


lUU,/OU 


C 71 Q 


( 1 


409 


7 QA 1 
/ ,o4 I 




Q H7Q 

y ,u f y 


Q A QQ 


0,Uo4 


£ OD/1 
D,Zo4 


c; 077 


Black 


27,710 


2,624 


2 


405 


2,695 


2,927 


2,855 


2,443 


2,061 


1,512 


1,288 


Male 4 


12,846 


1,324 


1 


212 


1,356 


1,464 


1,379 


1,147 


954 


688 


583 


Female 4 


14,323 


1,300 


1 


193 


1,339 


1,463 


1,477 


1,296 


1,107 


824 


706 


Percent: 
























1970 


100.0 


8.4 




9.8 


10.2 


9.4 


8.1 


6.6 


5.6 


5.5 


5.9 


1980 3 


100.0 


7.2 




7.4 


8.1 


9.3 


9.4 


8.6 


7.8 


6.2 


5.2 


1981, total 


100.0 


7.4 




7.0 


8.0 


8.9 


9.5 


8.8 


8.2 


' 6.3 


5.3 


Male 


100.0 


7.8 




7.4 


8.4 


9.3 


9.8 


9.0 


8.3 


6.4 


5.3 


Female 


100.0 


7.0 




6.7 


7.6 


8.5 


9.2 


8.5 


8.0 


6.2 


5.2 


White 


100.0 


7.0 




6.7 


7.7 


8.6 


9.3 


8.7 


8.2 


6.4 


5.3 


Black 


100.0 


9.7 




8.9 


9.9 


10.8 


10.5 


9 0 


7.6 


5.6 


4.7 



NA Not available 
x Not applicable. 

1 1ncludes other races, not shown separately 

2 The 1970 resident population count is 203,302,031; the difference of 66,733 is due to errors found after tabulations were completed. 

3 The data shown for April 1, 1980 are consistent with the 7980 Census of Population and Housing, Advance Reports, PHC80-V total count of 226,504,825. 

"The race data shown for April 1, 1980 have been modified. 

Source: U S Bureau of the Census, Census of Population: 1970, Vol 1. and Current Population Reports, Series P-25, No. 717 Taken from Statistical Abstract of the 
U S , 1982-83, U. S. Government Printing Office, Washington, DC, December 1982, Table 31, p 27 



28 



45-49 


50-54 


55-59 


60-64 


65-74 


75 years 


b-1 o 


14-17 


1 8-24 


16 years 


18 years 


Median 


years 


years 


years 


years 


years 


and over 


years 


years 


years 


and over 


and over 


age (yr.) 


12,124 


11,111 


9,979 


8,623 


12,443 


7,530 


36,675 


15,851 


23,714 


141,268 


133,546 


28.0 


5,855 


5,351 


4,769 


4,030 


5,440 


2,927 


1 8,68/ 


8,069 


1 1 ,583 


67,347 


63,41 9 


26.8 


6,269 


5,759 


5,210 


4,593 


7,002 


4,603 


17,987 


7,782 


12,131 


73,920 


70,127 


29.3 


10,868 


10,019 


9,021 


7,818 


11,300 


6,972 


31,171 


13,579 


20,655 


125,520 


118,884 


28.9 


b,2/U 


A Q A O 


A Q -1 Q 


O,b0O 


4,y<;o 


z,t>yu 


1 QOQ 

i o,y^y 




1 U, 1 oo 


DU,Uo4 


OD,DOU 


<L 1 .D 


5,598 


5,178 


4,702 


4,163 


6,374 


4,283 


15,242 


6,648 


10,521 


65,486 


62,234 


30.1 


1,124 


990 


874 


734 


1,043 


501 


5,009 


2,073 


2,721 


14,053 


13,065 


22.4 


520 


459 


405 


335 


461 


207 


2,510 


1,038 


1,282 


6,476 


5,981 


21.0 


603 


531 


469 


400 


582 


293 


2,499 


1,035 


1,438 


7,577 


7,084 


23.6 


1 1 ,088 


11,709 


11,614 


10,086 


15,578 


9,967 


(NA) 


(NA) 


(NA) 


(NA) 


(NA) 


30.0 


5,388 


5,620 


5,481 


4,669 


6,755 


3,547 


(NA) 


(NA) 


(NA) 


(NA) 


(NA) 


28.8 


5,701 


6,089 


6,133 


5,416 


8,822 


6,419 


(NA) 


(NA) 


(NA) 


(NA) 


(NA) 


31.3 


9,695 


10,362 


10,395 


9,078 


14,045 


9,1 16 


(NA) 


(NA) 


(NA) 


(NA) 


(NA) 


30.9 


4,756 


5,017 


4,929 


4,221 


6,095 


3,220 


(NA) 


(NA) 


(NA) 


(NA) 


(NA) 


29.6 


4,939 


5,345 


5,466 


4,857 


7,950 


5,896 


(NA) 


(NA) 


(NA) 


(NA) 


(NA) 


32.2 


1,148 


1 ,133 


1 ,040 


873 


1 ,343 


747 


(NA) 


(NA) 


(NA) 


(NA) 


(NA) 


24.9 


518 


506 


468 


386 


567 


281 


(NA) 


(NA) 


(NA) 


(NA) 


(NA) 


23.6 


630 


627 


572 


487 


776 


466 


(NA) 


(NA) 


(NA) 


(NA) 


(NA) 


26.2 


10,985 


1 1 ,545 


1 1 ,600 


10,335 


15,893 


10,361 


30,656 


15,565 


30,1 76 


1 74,327 


166,147 


30.3 


5,342 


5,546 


5,474 


4,782 


6,892 


3,668 


15,671 


7,940 


15,191 


83,316 


79,146 


29.1 


C CAQ 


r nnn 

o.yyy 




c: ceo 
0,000 


y,uuu 


o coo 

b.byo 


1/1 dO A 

\ 4,yo4 


1 ,b<ib 


1 4,yoo 


yi ,ui i 


o/ ,U0V 


O -1 c 

6\ .b 


9,574 


10,186 


10,360 


9,299 


14,322 


9,459 


25,196 


12,914 


25,397 


1 15,514 


144,718 


31.2 


4,701 


4,939 


4,917 


4,322 


6,221 


3,325 


12,916 


6,601 


12,848 


72,751 


69,279 


29.9 


4,873 


5,246 


5,443 


4,977 


8,102 


6,135 


12,281 


6,312 


12,549 


78,764 


75,439 


32.5 


1 ,148 


1 ,130 


1 ,046 


887 


1 ,363 


785 


4,570 


2,263 


4,049 


18,895 


17,712 


25.2 


517 


503 


466 


391 


571 


292 


2,302 


1 ,137 


1 ,972 


8,678 


8,084 


23.9 


631 


628 


579 


496 


791 


493 


2,268 


1 ,126 


2,077 


10,217 


9,628 


26.5 


6.0 


5.5 


4.9 


4.2 


6.1 


3.7 


18.0 


7.8 


11.7 


69.5 


65.7 


(x) 


4.9 


5.2 


5.1 


4.5 


6.9 


4.4 


(NA) 


(NA) 


(NA) 


(NA) 


(NA) 


(x) 


4.8 


5.0 


5.1 


4.5 


6.9 


4.5 


13.4 


6.8 


13.2 


76.0 


72.5 


(x) 


4.8 


5.0 


4.9 


4.3 


6.2 


3.3 


14.1 


7.1 


13.6 


74.8 


71.0 


(x) 


4.8 


5.1 


5.2 


4.7 


7.6 


5.7 


12.7 


6.5 


12.7 


77.2 


73.8 


(x) 


4.9 


5.2 


5.3 


4.7 


7.3 


4.8 


12.8 


6.6 


12.9 


77.1 


73.6 


(x) 


4.2 


4.2 


3.8 


3.3 


5.0 


2.9 


16.8 


8.3 


14.9 


69.5 


65.2 


(x) 



Table 3 

Spanish-origin population, by age and sex: 1980. 

[In thousands, except percent As of April.) 



65 

Item Total Under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-5455-59 60-64 years 

all 5 years years years years years years years years years years years years and 

years years over 

Total 14,609 1,663 1,537 1,475 1,606 1,586 1,376 1,129 854 712 622 564 454 321 709 

Male 7,280 848 783 747 827 819 697 558 416 345 300 270 217 147 305 

Female 7,329 815 754 728 780 767 679 570 438 367 321 294 237 174 404 

Percent Distribution 

Total 100.0 11.4 10.5 10.1 11.0 10.9 9.4 7.7 5.8 4.9 4.3 3.9 3.1 2.2 4.9 

Male 100.0 11.6 10.8 10.3 11.4 11.3 9.6 7.7 5.7 4.7 4.1 3.7 3.0 2.0 4.2 

Female 100.0 11.1 10.3 9.9 10.6 10.5 9.3 7.8 6.0 5.0 4.4 4.0 3.2 2.4 5.5 



Source: U.S. Bureau of the Census, 1980 Census of Population. Vol 1. chapter B (PC80-1B). Taken from Statistical Abstract of the U.S.: 1982-83, U.S. Government Prin- 
ting Office, Washington, DC, December 1982, Table 40, p. 35. 



Table 4 

Number and percent distribution of the total American Indian and Alaska Native population for 
reservation States and U.S. All races by age, 1980 census data. 

American Indian & 

Alaska Native U.S. All Races 





Number 


Percent 1 


Number 


Percent 1 


Total 


1,240,384 


100.000 


226,504,825 


100.000 


Under 5 years 


135,239 


10.903 


16,344,407 


7.216 


5 to 9 years 


131,735 


10.621 


16,697,134 


7.372 


10 to 14 years 


140,028 


11.289 


18,240,919 


8.053 


15 to 19 


150,897 


12.165 


21,161,667 


9.343 


20 to 24 years 


128,304 


10.344 


21,312,557 


9.409 


25 to 29 years 


107,131 


8.637 


19,517,672 


8.617 


30 to 34 year. 


91,175 


7.351 


17,557,957 


7.752 


35 to 39 years 


71,100 


5.732 


13,963,008 


6.165 


40 to 44 years 


58,755 


4.737 


11,668,239 


5.151 


45 to 49 years 


49,460 


3.988 


11,088,383 


4.895 


50 to 54 years 


43,954 


3.544 


11,708,984 


5.169 


55 to 59 years 


38,270 


3.085 


11,614,054 


5.128 


60 to 64 years 


29,234 


2.357 


10,085,711 


4.453 


65 to 69 years 


24,737 


1.994 


8,780,844 


3.877 


70 to 74 years 


17,243 


1.390 


6,796,742 


3.001 


75 to 79 years 


11,871 


0.957 


4,792,597 


2.116 


80 to 84 years 


6,105 


0.492 


2,934,229 


1.295 


85 years & over 


5,146 


0.415 


2,239,721 


0.989 



1 Percentages may not add to the totals due to rounding 

Source: Taken from FY 1984 Budget Appropriation, Indian Health Service "Chart Series" Tables. Population Branch. Office of 
Program Statistics, Division of Resource Coordination. Indian Health Service, Rockville, MD. March 1983 



30 



Table 5 

Social and economic characteristics of population, by race and Spanish origin, 1980. 

[In thousands, except as indicated. As of April. Provision data based on the Early National Sample from the 1980 census ] 



Race 



Race 









Asian 


Span- 


Characteristics 






and 


ish 




White 


Black 


Pacific 
Island- 
er 


origin 1 


FAMILY TYPE 










Total families 


50,448 


6,093 


828 


3,288 


With own children 2 . 


24,926 


3,714 


509 


2,229 


Married couple 


43,327 


3,466 


700 


2,463 


With own children 2 . 


21,222 


2,000 


449 


1,692 


Female householder 3 . . . 


5,590 


2,273 


90 


651 


With own children 2 . 


3,136 


1,565 


51 


472 


Male householder 3 


1,531 


354 


38 


174 


With own children 2 . 


568 


149 


10 


64 



Characteristics 







Asian 


Span- 






and 


isl i 


White 


Black 


Pacific 


origin 1 






Island- 








er 




114,301 


13,189 


2,110 


6,727 


19,013 


3,651 


360 


2,749 


16,736 


2,867 


1 85 


1 ,067 


40,628 


3,802 


506 


1,607 


18,307 


1 ,763 


371 


788 


19,617 


1,106 


686 


515 


16.6 


27.7 


17.1 


40.9 


14.6 


21.7 


8.8 


15.9 


35.5 


28.8 


24.1 


23.9 


16.0 


13.4 


17.6 


11.7 


17.2 


8.4 


32.5 


7.7 


145,447 


18,307 


2,698 


9,580 


90,507 


10,838 


1 ,788 


6,075 


62.2 


59.2 


66.3 


63.4 


89,340 


10,574 


1 ,751 


5,974 


84,134 


9,301 


1 ,666 


5,421 


5,205 


1,273 


86 


553 


5.8 


12.0 


4.9 


9.3 


69,705 


8,388 


1 ,290 


4,719 


52,949 


5,494 


964 


3,701 


76.0 


66.7 


76.3 


78.4 


51 ,881 


5,363 


950 


3,607 


48,837 


4,675 


907 


3,294 


"3 Odd 


uoo 


d? 


?1 A 

O 1 H 


5.9 


12.8 


4.4 


8.7 


75,742 


9,919 


1,406 


4,861 


37,558 


5,244 


804 


2,375 


49.6 


52.9 


57.1 


48.9 


37,459 


5,211 


802 


2,367 


35,298 


4,626 


758 


2,128 


2,161 


585 


43 


239 


5.8 


11.2 


5.4 


10.1 



Percent distribution: 
Total families 

With own children 2 
Married couple 

With own children 2 
Female householder 3 . . 

With own children 2 
Male householder 3 .... 

With own children 2 

FAMILY INCOME, 1979 



100.0 


100.0 


100.0 


100.0 


49.4 


61.0 


61.5 


67.8 


85.9 


56.9 


84.5 


74.9 


42.1 


32.8 


54.2 


51.5 


11.1 


37.3 


10.9 


19.8 


6.2 


25.7 


6.2 


14.4 


3.0 


5.8 


4.6 


5.3 


1.1 


2.4 


1.2 


1.9 



Less than $5,000 

$5,000-$9,999 

$10,000-$1 4,999 

$15,000-$1 9,999 

$20,000-$24,999 

$25,000-$34,999 

$35,000-$49,999 

$50,000 or more 



50,448 


65,093 


826 


3,288 


2,787 


1,183 


68 


454 


6,057 


1,281 


91 


622 


7,223 


1,020 


103 


600 


7,760 


817 


104 


500 


7,516 


613 


108 


399 


10,259 


720 


162 


477 


5,724 


344 


122 


186 


3,122 


115 


71 


78 



Median income (dol) 

Percent distribution: 

Total 

Less than $5,000 . . 

$5,000-$9,999 

$10,000-$14,999 . . . 
$15,000-$19,999 . . . 
$20,000-$24,999 . . 
$25,000-$34,999 . . . 
$35,000-$49,999 . 
$50,000 or more . . . 



20,840 12,618 22,075 14,711 



100.0 
5.5 
12.0 
14.3 
15.4 
14.9 
20.3 
11.3 
6.2 



100.0 
19.4 
21.0 
16.7 
13.4 
10.1 
11.8 
5.6 
1.9 



100.0 
8.2 
11.0 
12.4 
12.6 
13.0 
19.6 
14.7 
8.6 



100.0 
13.8 
18.9 
18.2 
15.2 
12.1 
13.6 
5.7 
2.4 



Total persons 189,079 26,505 3,698 14,589 



YEARS OF SCHOOL COMPLETED 

Persons 25 years and over 

Elementary: 0-8 years 

High school: 

1 -3 years 

4 years 

College: 

1 -3 years 

4 or more years 



Percent distribution: 
Elementary: 0-8 years 
High school: 

1-3 years 

4 years 

College: 

1 -3 years 

4 or more years . . . 



LABOR FORCE STATUS 

Persons 16 years old and over 

In labor force 

Percent 

In civilian labor force 

Employed 

Unemployed 

Percent 



Males 16 years old and over 

In labor force 

Percent 

In civilian labor force . . . 

Employed 

Unemployed 

Percent 



Females 16 years old and over 

In labor force 

Percent 

In civilian labor force 

Employed 

Unemployed 

Percent 



1 Persons of Spanish origin may be of any race. 
2 Children under 18 years old 
3 With no spouse present. 

Source: U.S. Bureau of the Census, 1980 Census of Population and Housing. 
Taken from Statistical Abstract of the U.S.. 1982-83, U.S. Government Printing 
Table 41. p, 35. 



Supplementary Report, series PHC 80-S1-1. 
Office, Washington, DC, December 1982, 



31 



Table 6 

Persons below poverty level, by age, region, race, and Spanish origin: 1981. 

[As of March 1981 Based on Current Population Survey. Based on householder concept and restricted to primary families.] 

Number Below Poverty Percent Below Poverty 
Level (1,000) Level 



Age and Region 


Ail 






Spanish 


All 






Spanish 




races 1 


White 


Black 


origin 2 


races 1 


White 


Black 


origin 2 


Total 


31 ,822 


21 ,553 


9,173 


3,713 


1 4.0 


1 1.1 


34.2 


26.5 


Under 16 years 


11,223 


7,009 


3,777 


1,727 


20.5 


15.7 


45.8 


36.3 


16 to 21 years 


3,867 


2,477 


1,242 


494 


15.9 


12.2 


36.8 


27.8 


22 to 44 years 


8,754 


6,154 


2,251 


1,010 


11.1 


9.1 


25.2 


20.1 


45 to 64 years 


4,125 


2,934 


1,083 


336 


9.3 


7.5 


25.8 


17.8 


65 years and over . . . 


3,853 


2,978 


820 


146 


15.3 


13.1 


39.0 


25.7 


Northeast 


5,815 


4,102 


1,629 


931 


11.9 


9.5 


33.2 


37.7 


North Central 


7,142 


5,205 


1,759 


164 


12.3 


10.0 


32.4 


16.5 


South 


13,256 


7,855 


5,192 


1,311 


17.4 


12.9 


37.1 


27.4 


West 


5,609 


4,391 


594 


1,307 


12.7 


11.5 


23.7 


22.6 



'Includes races not shown separately 
2 Persons of Spanish origin may be of any race 

Source: U.S. Bureau of the Census, Current Population Reports, series P-60, No. 134, and earlier issues. Taken from 
Statistical Abstract of the United States: 1982-83, U S Government Printing Office, Washington, DC, December 1982, Table 
729, p 442 



32 



Table 7 

Live births, birth rates, and fertility rates, by race of child: United States, specified years 1940-60 
and each year 1965-80. 

[Birth rates per 1,000 population in specified group. Fertility rates per 1,000 women aged 15-44 years in specified group. 
Population enumerated as of April 1 for census years and estimated as of July 1 for all other years. Beginning 1970 excludes 
births to nonresidents of the United States ] 







Number 






Birth 


rate 






Fertility rate 




Year 


All 

r\\ I 




All other 


All 


White 


All other 


All 


White 


All other 






White 


I 0I3I 


biacK 




Tr\\ o 1 

i oiai 


biacK 




i otai 


tsiacK 


Registered births 


























1980 1 


3,612,258 


n qqq TOO 


713,526 


589,616 


15.9 


14.9 


22.5 


22.1 


68.4 


P.A ~7 
t>4. / 


88.6 


88.1 


1979 1 


3,494,398 


o QnQ Aon 


685,978 


577,855 


15.6 


14.5 


22.2 


22.0 


67.2 


CO A 
DO. 4 


88.5 


88.3 


1978 1 


3,333,279 


£,Oo I , l I D 


652,163 


551,540 


15.0 


14.0 


21.6 


21.3 


65.5 


d 7 
Dl . / 


87.0 


86.7 


1977 1 


3,326,632 


^,oyi ,u/u 


635,562 


544,221 


15.1 


14.1 


21.6 


21.4 


66.8 


CO O 


87.7 


88.1 


1976 1 


3,167,788 


^,OD/ ,bl 4 


DUU, 1 / 4 


0 1 4,4 / y 


14.6 


13.6 


on q 


on c; 


65.0 


CM .0 


Q CZ Q 

OO.O 


Q C Q 
OO.O 


1975 1 


3,144,198 


2,551,996 


592,202 


511,581 


14.6 


13.6 


21.0 


20.7 


66.0 


62.5 


87.7 


87.9 


19741 


3,159,958 


2,575,792 


584,166 


507,162 


14.8 


13.9 


21.2 


20.8 


67.8 


64.2 


89.8 


89.7 


1973 1 


3,136,965 


2,551,030 


585,935 


512,597 


14.8 


13.8 


21.7 


21.4 


68.8 


64.9 


93.4 


93.6 


1972 1 


O A r~ n A A -A 

3,258,41 1 


2,655,558 


602,853 


531,329 


15.6 


1 4.5 


22.8 


22.5 


73.1 


68.9 


99.5 


99.9 


1971 2 


o r~ r~ r~ 

3,555,970 


2,919,746 


636,224 


564,960 


1 7.2 


16.1 


24.6 


24.4 


81 .6 


77.3 


109.1 


109.7 


1970 2 


3,731 ,386 


3,091,264 


640,122 


572,362 


18.4 


17.4 


25.1 


25.3 


87.9 


84.1 


113.0 


1 15.4 


1969 2 


3,600,206 


2,993,614 


606,592 


543,132 


17.9 


16.9 


24.5 


24.4 


86.1 


82.2 


111.6 


1 12.1 


1968 2 


3,501,564 


2,912,224 


589,340 


531,152 


17.6 


16.6 


24.2 


24.2 


85.2 


81.3 


111.9 


112.7 


19b / d 


o,5^(j,y5y 


2,922,502 


598,457 


543,976 


H "7 O 
1 7.8 


1 O.O 


25.0 


25.1 


8/ .<L 


82.8 


117.1 


118.5 


1966 2 


3,606,274 


2,993,230 


613,044 


558,244 


18.4 


17.4 


26.1 


26.2 


90.8 


86.2 


123.5 


124.7 


1965 2 


3,760,358 


3,123,860 


636,498 


581,126 


19.4 


18.3 


27.6 


27.7 


96.3 


91.3 


131.9 


133.2 


I960 2 


4,257,850 


3,600,744 


657,106 


602,264 


23.7 


22.7 


32.1 


31.9 


118.0 


113.2 


153.6 


153.5 


Births adjusted 


























for underregistration 


























1955 


4,097,000 


3,485,000 


613,000 




25.0 


23.8 


34.5 




118.3 


113.7 


154.3 




1950 


3,632,000 


3,108,000 


524,000 




24.1 


23.0 


33.3 




106.2 


102.3 


137.3 




1945 


2,858,000 


2,471,000 


388,000 




20.4 


19.7 


26.5 




85.9 


83.4 


106.0 




1940 


2,559,000 


2,199,000 


360,000 




19.4 


1 8 6 


26.7 




79.9 


77.1 


102.4 





'Based on 100 percent of births in selected States and on a 50-percent sample of births in all other States; see Technical 
notes. 

2 Based on a 50-percent sample of births. 
3 Based on a 20- to 50-percent sample of births. 
Note: Rates for 1971-79 have been revised 

Source: National Center for Health Statistics: Advance report of final natality statistics. 1980 Monthly Vital Statistics Report, 
Vol. 31, No. 8 supplement, November 30, 1982, Table 1, p 9. 



rable 8 

Birth rates by Hispanic origin of mother, and by race of child for mothers of non-Hispanic origin: 
22 reporting States, 1980. 

[Rates per 1,000 population in specified group] 



Origin of mother 



State of residence 








Hispanic 








Non-Hispanic 1 






All 


Total 


Mexican 


Puerto 


Cuban 


Other 


Total 3 


White 


Black 




origins 1 






Rican 




Hispanic 2 


mm reporting otates . . . 


1 R 4 
I O.^ 


9ft R 
tiO.O 


9R R 
^D.D 


90 ft 


Q R 

y .o 


90 n 


1 R R 
I O.O 


14 9 


99 Q 
dc. .y 


Arizona 


1 ft A 
I 0.4 


9R ft 


97 Q 
tL 1 .y 


14ft 

I *4-.o 


1 ft 1 * 

I O. I 


11ft 
I I .o 


1 R Q 

I u.y 


1 O.o 


9R ft 


Arkansas 


1 R ft 
I O.o 


1 ft 7 
I J./ 


7 ft 
/ .O 


1 ft ft * 
I o.o 


94 ft * 


OR ft 


1 R ft 
I D.O 


1 4 R 
I 4.D 


OA ft 


\^cx\ I iui I lid 


1 7 n 


25.3 


27.7 


1 3.2 


9.5 


16.2 


1 5.1 


1 3.8 


22.4 


L/OIOldUO 


1 7 9 

I / .{L 


91 R 
c. I .O 


1C 7 
1 o. / 


1 R 0 

I O.U 


114* 
I I ,H 


ft1 4 


1 R R 
I D.O 


1 R 1 
I D. I 


9ft 9 

£0 . £ 


rioriud 


i o.o 


1 ft 7 
I o. / 


99 ft 


1 R 7 


Q R 
y.o 


1 ft R 


1ft R 
I o.o 


114 


9R 4 


ijeoigid 


1 R Q 
I D.y 


10 4 


7 R 

/ . o 


i / .y 


i?.U 


117 
ii./ 


1 7 0 
I / . u 


1 4 R 

I H-.U 


9ft ft 


Hawaii 


1 ft ft 
I O.O 


9R 1 
c.D. I 


OA 7 


9R Q 
£_o.y 


4R Q* 


94 0 


1 ft ft 
I o.o 


I £.D 


ftft 1 

OO. I 


Illinois 


1 D.D 


9ft n 


97 ft 
c. 1 .0 


90 O 


119 
i i .d. 


4ft 4 


1 R O 
I D.U 


14 9 


94 7 


maiana 


I D. I 


1 Q 1 

i y. i 


1 Q Q 

i y .y 


1 Q 4 


110 
I I .u 


1 R 7 
ID./ 


1 R 1 
I D. I 


i o.^+ 


9ft ft 

ilO.O 


rxansds 


17 9 


90 ft 


90 0 


9Q 1 
^_y. i 


7 fi* 
/ .u 


90 4 


1 7 1 
i / . I 


1 R 4 


97 9 


iviame 


1 ^.O 


Q ft 

y.o 


R ft* 
O.o 


1 4 O * 
I H.U 


1 4 fi * 
I t.o 


1 0 R 
I U.D 


1 4 7 


1AC 
i ^+.o 


9R 1 


MISSISSIPPI 


1 Q n 
i y .u 


A Q 


ft O 

o.U 


1 ft 9 * 

I O.^l 




7 R 
/ .D 


1 Q 1 
i y. i 


m ft 

I o.o 


9R Q 




17.4 


22.9 


25.2 


8.0* 


1 1 .0* 


15.0 


17.3 


16.8 


27.1 


Nevada 


16.6 


20.6 


21.1 


9.2* 


6.7 


24.2 


16.4 


15.1 


25.8 


New Jersey 


13.2 


20.8 


14.7 


25.8 


10.6 


18.8 


12.6 


11.2 


21.1 


New Mexico 


20.0 


18.4 


18.3 4 


14.9 


6.6* 


18.3 4 


21.0 


19.0 


24.1 


New York 


13.6 


19.9 


16.5 


20.0 


8.0 


21.6 


13.0 


11.6 


19.8 


North Dakota 


18.4 


13.3 


13.8 






15.6 


18.4 


17.5 


42.2 


Ohio 


15.7 


18.0 


16.4 


23.1 


7.4 


16.3 


15.6 


14.9 


21.8 


Texas 


19.2 


26.7 


28.3 


17.4 


9.5 


5.8 


17.2 


16.1 


22.7 


Utah 


28.6 


28.1 


24.8 


6.7* 


81.3 


35.1 


28.6 


28.5 


22.7 


Wyoming 


22.5 


27.1 


25.7 


27.9* 




30.1 


22.2 


21.7 


32.3 



'Includes origin not stated. 

includes Central and South American and other and unknown Hispanic, 
includes races other than white and black 

4 Rate is births to Mexican and "other Hispanic" mothers per 1,000 Mexican and "other Hispanic" population; see Technical 
notes 

'Based on fewer than 20 births. 

Source: National Center for Health Statistics: S.J Ventura: Births of Hispanic Parentage, 1980. Monthly Vital Statistics Report- 
Vol 32, No 6 Supp DHHS Pub. No (PHS) 83-1120. Public Health Service, Hyattsville, MD. September 1983, Table 9, p 12. 



34 



Table 9 

Number and rate 1 of live births for Indians and Alaska Natives in reservation States, and U.S. 
All races. 1954-1979. 
[Rates per 1 .000 population] 





Indian and 


Indian 


Alaska 




U.S. 




U.S. Other 


Calendar 


Alaska Native 


(Reserv. 


States) 


Native 




All Races 




than White 


Year 


Number 


Rate 


M i i m hor 




Number 


Rate 


Number 


Rate 


Rate 


i Q7Q 

i y /y 


31,843 


— 


29,803 


— 


£,U4U 




P AQA PQQ 

o,4y4,oyo 






i y io 


29,857 


31.8 


27,922 


32.1 


i ,yoo 


no a 
do A 


p poo. nnn 

o,o^y,uuu 


i c p 

1 O.O 


OO A 


A 0.77 

\ y / / 


28,198 


31.5 


26,325 


31.7 


1 P7P 
\ ,0 / O 


no n 


P QOf: COO 

o.oVO, Ood. 


1 R A 

\ 0.4 


0 1 o 

iL \ .y 


1 Q7C 

\ y / o 


26,748 


30.9 


24,989 


31 .0 


1 7RQ 

i , / oy 


9Q 1 

<iy. I 


P 1 K7 7RR 
O, ID/,/ OO 


1 A R 
I 4.0 


01 1 
£ I . I 


1 Q7£ 

i y / o 


25,457 


30.7 


23,695 


30.7 


"I 7P.0 
I , / Od 


9Q Q 

<iy .y 


O A A A A QQ 

o, 1 44, i yo 


1 /I P 
I 4.0 


01 0 


1 Q"7/1 

\ y / 4 


24,301 


30.7 


22,653 


30.7 


1 PA Q 
I ,040 


P 1 A 

o \ .4 


o, i oy.yoo 


A A Q 

1 4.y 


01 /t 

^1 .4 


1 Q7Q 

i y / o 


23,757 


31.1 


22,087 


31 .1 


1 P7I~\ 


pn q 


p -i pa qpr 
o, i oo.yoo 


1 /I Q 

1 4,y 


0 1 Q 

^i .y 


-I Q"7Q 

i y / z 


23,752 


31.8 


22,154 


31.8 


1 RQQ 

i ,oyo 


P 1 R 
o I .0 


P ORQ A 1 1 
O,<i0o,4 I I 


A R P 

i o.o 


OO o. 


1 Q"7 1 

i y/ 1 


23,806 


32.4 


22,092 


32.4 


1 71/1 
1 , / 1 4 


0£. 1 


Q CCC Q7A 

o.ooo, y /u 


1 7 O 


O/l 7 

Z4. / 


i y /u 


22,746 


32.4 


21,100 


32.4 


A PAP 

1 ,04o 


PO 1 


P 7P 1 PPC 

o, /ol ,oob 


A Q A 




i yoy 


21,593 


32.3 


20,074 


32.3 


1 , j i y 


OA /I 
O I .4 


p cnn onK 
o,o(JU,<;Uo 


1 7 P 


O/l /l 


i yoo 


21,602 


32.2 


20,066 


32.2 


I ,OoO 


PO P 


O,0U I ,004 


17 c 

l / .0 


O/l 0 


i yo / 


20,658 


33.0 


18,948 


32.8 


1 71 r\ 
I , ( I u 


OR R 
JOB 


o.o^u.yoy 


1 7 P 
l / .O 




i yoo 


21,100 


34.5 


19,154 


34.1 


1 Q/l P 

i ,y4o 


PQ 7 

oy. / 


P Pt~\P 07 A 
O,0U0,£ / 4 


1 P A 
I O 4 


OA 1 


i yoo 


22,370 


36.4 


20,352 


36.0 


o ni p 

Z,U It) 


/I O P 

4^1. o 


p 7^n oco 
o, / oU.oOo 


\ y.4 


07 P. 


1 Q£/l 

i yt>4 


22,782 


38.4 


20,794 


37.9 


i ,yoo 


A A A 
44.4 


/i no7 Ao.n 
H,\jd i ,4yu 


o 1 n 


on 1 

^y. i 


A Q£P 

\ yoo 


22,274 


39.5 


20,142 


38.9 


O A OO 


/I c: 7 
40. / 


4,uyo,u^u 


0 1 7 


on 7 


1 962 


21,866 


40.8 


19,770 


40.2 


2,096 


47.2 


4 1 67 ^6? 


22.4 


30.5 


1961 


21,664 


41.7 


19,570 


41.2 


2,094 


46.8 


4,268,326 


23.3 


31.6 


1960 


21,154 


42.1 


19,188 


41.7 


1,966 


46.4 


4,257,850 


23.7 


32.1 


1959 


20,520 


41.4 


18,616 


40.9 


1,904 


46.7 


4,244,796 


24.0 


32.9 


1958 


19,371 


40.3 


17,428 


39.7 


1,943 


47.4 


4,203,812 


24.3 


33.0 


1957 


18,814 


39.1 


16,982 


38.2 


1,832 


49.3 


4,254,784 


25.0 


33.9 


1956 


17,947 


38.2 


26,040 


37.2 


1,907 


49.5 


4,168,090 


24.9 


33.9 


1955 


17,028 


37.5 


15,304 


36.5 


1,724 


49.5 


4,047,295 


24.6 


33.1 


1954 


16,691 




15,042 




1,649 











1 1ndian and Alaska Native rates are 3-year averages centered in the year specified for reservation States. All other rates are 
based on single year data. Estimated population methodology for the Indian and Alaska Native population revised for 1976. 
Maine, New York and Pennsylvania included as reservation States beginning in 1979. 

Source: Taken from FY 1984 Budget Appropriation, Indian Health Service "Chart Series" Tables. Vital Events Branch. Office 
of Program Statistics, Division of Resource Coordination Indian Health Service, Rockville, MD December 1981. 



35 



Table 10 

Fertility rates by Hispanic origin of mother, and by race of child for mothers of non-Hispanic 
origin: 22 reporting States, 1980. 

[Rates per 1,000 women aged 15-44 years in specified group] 



Origin of mother 



State of residence 








I lispcinir, 








Non-Hispanic 1 






All 


1 otal 


Mexican 


Puerto 


Cuban 


Other 


I otal 3 


White 


Black 




origins 1 






Rican 




Hispanic 2 




Mil ItipUtlUiy OldlUb . . . 


70 9 

/ \J.C. 


4 


111 Q 

I I I .o 


77 n 


41 Q 

4 1 .J 


7^ 9 


fi7 1 
o / . I 


fi9 4 


QD 7 


MllZOlId 


ftfl 1 

OU. I 


1 in q 


11 7 fi 
I I / .u 


fin ? 


^fiS 1 
JJ. I 


47 1 

H / . I 


74 0 


fi7 4 


1 1 R 9 


Ml r\dl lodo 


74 P 


S8 S 


8? 7 


*fiO 7 


* -j 07. 1 


Q8 fi 

uU . U 


74 8 


fifi 8 


111ft 
I I I . o 


f"!pi I if nr nip 


70.8 


102.1 


1 14.6 


52.9 


39.7 


59.1 


63.1 


58.9 


86.3 


r\\ r> r a r\r\ 


fi7 Q 


87 n 

(J / . VJ 


fift Q 


63.3 


*4 C > 7 


1 25.4 


fi^ 4 

UU . *T 


fift 4 

UU . *T 


QO ft 
zjyj . u 


PlnriHa 


fi4 1 


S8 8 


1 m 4 

I UU . " 


64.3 


42 8 


71 8 

/ U . O 


64.7 


Sfi R 

UU . U 


in? 1 




fiQ fi 

U ZJ . U 


4? S 


32.0 


77.0 


40.3 


43.9 


69.9 


61 .1 


Q? 1 


I — I Q\A/Q 1 1 

ndwdll 


7ft Q 

( O.ZJ 


1 Dft ft 

I UU . U 


1 nn n 


1 ?4 Q 


*?0fi Q 

C-\J\J . ZJ 


Q'S 7 

UU. / 


7fi Q 




1 7ft Q 


1 1 1 1 nc-u c 

Mill lUlb 


71 ? 


1 1 S 9 

I IJ.il 


117ft 
I i / . o 


7fi o 


4S R 


1 ft9 Q 

I OiC . ZJ 


fi8 fi 

Uu.U 


fi? 7 




InHionQ 


RQ 1 

Uc7. I 


ftO S 

Ou. J 


87 n 


78 7 


41 ft 


84 7 


fi8 Q 

DO . C7 


fifi 7 


Q8 Q 




7F> Q 

/ U . zj 


ftft S 

UU . U 


8Q 8 

UC . U 


1 80 fi 


U I -O 


78 8 

/ U . U 


76.5 


78 fi 

/ u . u 


1 1 4.6 


t\A q i no 


84 ft 


41 8 


*?7 Q 

C. f .ZJ 


*fin fi 

UU . U 


*fi1 ? 

U I 


42.1 


fi4 9 

\J'-T . U 


fi4 4 


1 8Q 1 


t\A 1 CCI CCI PlPlI 


ft? Q 

UJ . ZJ 


20 Q 

C-\J . ZJ 


1 8 fi 






80 fi 

UU . VJ 


84.6 


fi8 1 

UU . I 


1 1 8 ft 

I I U . U 




77 4 


Qft 4 

ZJO . H 


1114 


*8S 7 

UU . f 


*sn fi 

UU . U 


Sfi 4 

UU . *-r 


77 n 

/ / . U 


7fi 9 


1 07 fi 

I u / ,U 


Nevada 


68.4 


83.6 


88.0 


*38.8 


28.4 


91 .8 


67.3 


62.9 


97.8 


New Jersey 


57.4 


79.4 


61.2 


97.2 


43.2 


70.3 


55.6 


50.7 


80.1 


New Mexico 


84.1 


75.5 


75. 6 4 


62.7 


*27.8 


75. 6 4 


89.3 


82.0 


104.3 


New York 


58.5 


73.9 


68.2 


74.5 


36.2 


77.4 


56.6 


52.4 


74.2 


North Dakota 


82.4 


55.0 


57.9 






61.5 


82.6 


78.9 


206.2 


Ohio 


67.5 


74.8 


71.8 


93.0 


31.3 


64.9 


67.5 


64.9 


87.2 


Texas 


81.0 


112.2 


119.7 


72.8 


37.7 


22.8 


72.7 


68.7 


92.1 


Utah 


123. 




















0 


119.5 


109.9 


*27.9 


242.1 


139.6 


123.2 


122.8 


107.6 


Wyoming 


94.8 


118.2 


115.2 


•111.1 




124.9 


93.5 


91.6 


145.4 



1 1ncludes origin not stated 

includes Central and South American and other and unknown Hispanic, 
includes races other than white and black 

4 Rate is births to Mexican and "other Hispanic" mothers per 1,000 Mexican and "other Hispanic" population; see Technical 
notes 

'Based on fewer than 20 births 

Source. National Center for Health Statistics S J Ventura Births of Hispanic Parentage, 1980 Monthly Vital Statistics Report 
Vol 32, No 6 Supp DHHS Pub No (PHS) 83-1120 Public Health Service, Hyattsville, MD September 1983, Table 10, 
p 13 



36 



Table 11 



Total fertility rate and intrinsic rate of natural increase: 1940-1979. 

[Excludes Alaska prior to 1959 and Hawaii prior to 1960. Prior to 1960, based on births adjusted for underregistration, 
thereafter, registered births only. Beginning 1970, excludes births to nonresidents of United States. The total fertility rate is the 
number of births that 1 ,000 women would have in their lifetime if, at each year of age, they experienced the birth rates occur- 
ring in the specified year. A total fertility rate of 2,110 represents "replacement level" fertility for the total population under 
current mortality conditions (assuming no net immigration). The intrinsic rate of natural increase is the rate that would even- 
tually prevail if a population were to experience, at each year of age, the birth rates and death rates occurring in the 
specified year and if those rates remained unchanged over a long period of time Minus sign (-) denotes decrease ] 



Intrinsic Rate of Intrinsic Rate of 

Total Fertility Rate Natural Increase Total Fertility Rate Natural Increase 



Year 


Total 


White 


Black 
and 
other 


Total 


White 


Black 
and 
other 


Year 


Total 


White 


Black 
and 
other 


Total 


White 


Black 
and 
other 


1940-44 . . 


2,523 


2,460 


3,010 


4.6 


3.9 


9.8 


1968 . 


2,464 


2,366 


3,108 


5.9 


4.2 


16.0 


1945-49 . . 


2,985 


2,916 


3,485 


11.7 


10.9 


17.2 


1 969 


2,456 


2,360 


3,061 


5.7 


4.1 


15.4 


1950-54 . . 


3,337 


3,221 


4,185 


16.8 


15.4 


25.7 


1970 


2,480 


2,385 


3,067 


6.0 


4.5 


14.4 


1955-59 . . 


3,690 


3,549 


4,716 


21.1 


19.5 


30.7 


1971 . . 


2,275 


2,168 


2,933 


2.8 


1.0 


12.8 


1960-64 . . 


3,449 


3,326 


4,326 


18.6 


17.1 


27.7 


1972 


2,022 


1,918 


2,651 


-1.7 


-3.7 


8.9 


1965-69 


2,622 


2,512 


3,362 


8.2 


6.4 


18.6 


1973 


1,896 


1,798 


2,474 


-4.2 


-6.1 


6.1 


1970-74 . . 


2,106 


2,007 


2,700 


-.4 


-2.2 


9.4 


1974 


1,857 


1,768 


2,377 


-5.0 


-6.8 


4.6 


1975-79 . . 


1,810 


1,717 


2,334 


-5.8 


-7.8 


4.1 


1975 


1,799 


1,708 


2,322 


-6.1 


-8.1 


3.7 
















1976 


1,768 


1,679 


2,276 


-6.7 


-8.6 


3.0 


1965 


2,913 


2,783 


3,808 


12.1 


10.3 


23.1 


1977 


1,826 


1,735 


2,343 


-5.4 


-7.4 


4.3 


1966 


2,721 


2,603 


3,532 


9.7 


7.9 


20.4 


1978 


1,800 


1,704 


2,334 


-6.0 


-8.0 


4.1 


1967 


2.558 


2,447 


3,299 


7.4 


5.6 


18.2 


1979 


1,856 


1,758 


2,395 


-4.7 


-6.8 


5.2 



Source: U.S: National Center for Health Statistics. Vital Statistics of the U.S., annual and unpublished data. Taken from U S 
Bureau of the Census, Statistical Abstract of the U.S. 1982-83, U.S. Government Printing Office, Washington, DC December 
1982. Table 85, p. 60 



37 



Table 12 

Unwanted births of all mothers, 15-44 years old: 1973 and 1976. 

[Data represent the birth experience to date of all mothers 15-44 years old who have been married or are single with children 
of their own in the household. From the 1973 and 1976 National Survey of Family Growth; based on a multi-stage area 
probability sample Data are subject to sampling variability.] 



1973 1976 









Unwanted 






Unwanted 








Num- 




births 2 


Num- 




births 2 




Unwant- 


Characteristic 


ber of 


Total 






ber of 


Total 






All 


ed 2 




moth- 


live 


Num- 




moth- 


live 


Num- 




births 


births 




ers 


births 1 


ber 


Per- 


ers 


births 1 


ber 


Per- 


per 


per 




(1,000) 


(1,000) 


(1,000) 


cent 


(1,000) 


(1,000) 


(1 ,000) 


cent 


mother 


mother 


Total mothers 3 


25,803 


68,184 


8,910 


13.1 


27,055 4 


67,849 4 


8,125 


12.0 


2.51 


.30 


Race: 






















White 


22,182 


57,551 


6,068 


10.5 


22,837 


56,238 


5,350 


9.5 


2.46 


.23 


Black 


3,359 


9,984 


2,783 


27.9 


3,726 


10,525 


2,716 


25.8 


2.82 


.73 


Education: 






















Less than high school 


2,622 


9,123 


1,501 


16.5 


2,187 


7,274 


1,264 


17.4 


3.33 


.58 


High school: 1-3 years 


5,697 


16,884 


3,024 


17.9 


5,478 


15,543 


2,405 


15.5 


2.84 


.44 


4 years 


12,161 


29,917 


3,307 


11.1 


12,651 


30,405 


3,391 


11.2 


2.40 


.27 


College: 1-3 years 


3,182 


7,585 


734 


9.7 


3,763 


8,391 


776 


9.3 


2.23 


.21 


4 years or more 


2,140 


4,675 


344 


7.4 


2,925 


6,1 14 


286 


4.7 


2.09 


.10 


Currently married mothers 3 . . 


21,816 


57,524 


6,418 


11.2 


22,253 4 


55,900" 


5,516 


9.9 


2.51 


.25 


Race: 






















White 


19,764 


51,391 


5,055 


9.8 


19,921 


49,453 


4,299 


8.7 


2.48 


.22 


Black 


1,822 


5,561 


1,331 


23.9 


1,927 


5,533 


1,177 


21.3 


2.87 


.61 


Education: 






















Less than high school 


1,948 


6,846 


838 


12.2 


1,663 


5,584 


832 


14.9 


3.36 


.50 


High school: 1-3 years 


4,482 


13,274 


2,114 


15.9 


3,951 


11,226 


1,320 


11.8 


2.84 


.33 


4 years 


10,646 


26,494 


2,586 


9.8 


10,741 


26,120 


2,547 


9.8 


2.43 


.24 


College: 1-3 years 


2,816 


6,722 


602 


9.0 


3,244 


7,381 


597 


8.1 


2.28 


.18 


4 years or more 


1,924 


4,187 


279 


6.7 


2,613 


5,503 


219 


4.0 


2.11 


.08 



1 Multiple births counted only once. 

2 AII births which mothers report as "not wanted" or "probably not wanted" at time of becoming pregnant 
includes races not shown separately 
"Includes education not reported 

Source: U.S. National Center for Health Statistics. Wanted and Unwanted Births Reported by Mothers. 15-44 Years of Age 
United States. 1973 and 1976 Advanced Data from Vital and Health Statistics, HRA 77-1250; and unpublished data. Taken 
from U.S. Bureau of the Census, Statistical Abstract of the United States 1982-83, U.S. Government Printing Office, 
Washington, DC December 1982, Table 99. p 67 



38 



Table 13 

Contraceptive use by currently married women 15-44 years old, by age, race, and method of contraception: 1965 to 1976. 

[1965 data from National Fertility Survey; 1973 and 1976 data] 



Race and Method of Contraception 


1 Otdl, 


15-44 years old 


1 5-29 years old 


30-44 years old 


1965 


1973 


1976 


1 965 


1973 


1976 


1965 


1973 


1976 


White Women 




















Currently marneu (i.uuu) 




24,249 


24,795 


9,166 


10,963 


11,218 


14,261 


13,286 


13,577 


Percent using contraception 


b4. 1 


70.5 


68.8 


63.4 


70.7 


70.0 


64.5 


70.4 


67.8 


Percent distribution of users of contraception . 


-i nn n 
1 UU.U 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


Wife sterilized 


c c 
D.D 


1 1 .b 


-ion 

i o.y 


O Q 

2.8 


0. / 


b. 1 


Q 1 


-ICC 

1 b.O 


on c 
2U.0 


Husband sterilized 


5 5 


11.9 


14.2 


3.2 


5.6 


6.0 


7.0 


17.1 


21.1 


Pill 


24.0 


36.6 


32.9 


42.4 


52.9 


50.6 


12.8 


21.2 


17.8 


Intra-uterine device 


1.11 


9.4 


9.2 


1.51 


11.9 


10.5 


.8 1 


7.4 


8.1 


f~^i onh ron m 


1 n 4 


3.6 


4.4 


6.6 


2.6 


4.1 


12.8 


4.4 


4.6 


Pnn Hnm 


?? 4 


14.1 


10.9 


19.2 


10.5 


9.7 


24.4 


17.1 


1 1 .9 






5.0 


4.2 


4.5 


5.3 


4.8 


2.2 


4.7 


3.8 


Ph\/+hm 


11 r; 


4.1 


5.1 


8.0 


2.0 


4.0 


13.7 


5.9 


6.1 


All nthnr 


I o.o 


4.8 


5.3 


11.9 


3.5 


4.3 


17.7 


5.9 


6.1 


Black Women 




















Currently marneo (i ,uuu) 


o no 1 


2,081 


2,169 


(NA) 


964 


993 


(NA) 


1,117 


1,177 


Percent using contraception 


ceo 
ob. 2 


60.0 


58.6 


62.2 


63.7 


61.0 


51.1 


56.8 


58.5 


Percent distribution of users of contraception . 


1 UU.U 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


Wife sterilized 


-ICO 

1 O.O 


22.7 


18.7 


7.4 


9.8 


8.6 


23.4 


35.2 


27.9 


Husband sterilized 


.6 1 


1.71 


3.0 1 


.4 1 


.71 


.3 1 


.7 1 


2.7 1 


5.4 1 


Pill 


21.6 


43.8 


38.0 


30.9 


63.9 


56.0 


12.3 


24.3 


21.5 


Intra-uterine device 


2.8 


12.7 


10.6 


4.8 


13.1 


9.1 


.7 


12.4 


11.9 


Diaphragm 


5.0 


2.0' 


3.0 1 


3.3 


1.21 


I.41 


6.7 


2.8 1 


4.5 1 


Condom 


17.4 


5.3 


7.9 


18.7 


3.1 1 


8.4 


16.0 


7.5 


7.4 


Foam 


6.3 


5.0 


6.5 


8.1 


3.5 


4.9 


4.5 


6.6 


8.0 


Rhythm 


2.6 


1.3 1 


2.4 1 


2.9 


1.61 


3.1 1 


2.2 


.9 1 


1.81 


All other 


28.5 


5.3 


10.0 


23.5 


3.1 


8.3 


33.5 


7.8 


11.6 



NA— Not available. 

'Figure does not meet standards of reliability or precision 

Source: 1) "Trends in Contraceptive Practice; 1965-1973 " In Alan Guttmacher Institute, Family Planning Perspectives, vol 8, 
No. 2, 1976. 2) National Center for Health Statistics: Vital and Health Statistics, Series 23, No 10, DHHS Pub. No. 82-1986 
Taken from U.S. Bureau of the Census, Statistical Abstract of the United States 1982-83 U S Government Printing Office, 
Washington, DC December, 1982. Table 100, p. 68. 



39 



Table 14 

Age-adjusted death rates by race and sex: death registration States, selected years 1900-30, and United 
States selected years 1940-80. 



Area and year 




Total 






White 






All Other 




Both 

sexes 


Male 


Female 


Both 
sexes 


Male 


Female 


Both 
sexes 


Male Female 










Rates per 1 ,000 population 








UNITED STATES 




















1980 


5.9 


7.8 


4.3 


5.6 


7.5 


4.1 


7.7 


10.2 


5.8 


1970 1 


7.1 


9.3 


5.3 


6.8 


8.9 


5.0 


9.8 


12.3 


7.7 


1960 


7.6 


9.5 


5.9 


7.3 


9.2 


5.6 


10.5 


12.1 


8.9 


1950 


8.4 


10.0 


6.9 


8.0 


9.6 


6.5 


12.3 


13.6 


10.9 


1940 


10.8 


12.1 


9.4 


10.2 


11.6 


8.8 


16.3 


17.6 


15.0 


DEATH- 




















REGISTRATION 




















STATES 2 




















1930 


12.5 


13.5 


11.3 


11.7 


12.8 


10.6 


20.1 


21.0 


19.2 


1920 


14.2 


14.7 


13.8 


13.7 


14.2 


13.1 


20.6 


20.4 


21.0 


1910 


15.8 


16.9 


14.6 


15.6 


16.7 


14.4 


24.1 


24.8 


23.2 


1 900 


17.8 


18.6 


17.0 


17.6 


18 4 


16.8 


27.8 


28.7 


27.1 



(Computed by the direct method, using as the standard population the age distribution of the total population of the United 

States as enumerated in 1940 ) 

'Excludes deaths of nonresidents of the United States 

increased in number from 10 States and the District of Columbia in 1900 to the entire coterminous United States in 1933. 
Source: Compiled and abstracted by CHESS from 1) National Center for Health Statistics: Vital Statistics of the United States, 
1973, vol II, Mortality, Part A 2) Department of Health, Education, and Welfare Monthly Vital Statistics Report, Summary 
Report, Final Mortality Statistics, 1980, vol 32, No 4 



Table 15 

Age-adjusted mortality rates 

American Indians and Alaska Natives in reservation States and selected U.S. populations by race, 1979. 

[Number of deaths per 100,000 population) 





Indians 
and Alaska 
Natives 


United States 
All Races White 


All 
Other 


Ratio of 
Indians 
to U.S. 
All Races 


All Causes 


770.2 


588.8 


563.4 


776 3 


1.3 


Major cardiovascular disease 


219.1 


259.3 


252.6 


313.6 


0.8 


Diseases of heart 


173.2 


203.5 


199.8 


232.8 


0.9 


Cerebrovascular disease 


38.7 


42.5 


39.8 


65.1 


0.9 


Atherosclerosis 


5.2 


5.7 


5.7 


5.6 


0.9 


Hypertension 


2.1 


1.9 


1.6 


5.1 


1.1 


Accidents 


140.7 


43.7 


42.9 


50.5 


3.2 


Motor vehicle 


79.3 


23.7 


24.3 


21.5 


3.3 


All Other 


61.4 


20.0 


18.6 


29.0 


3.1 


Malignant neoplasms 


78.9 


133.2 


130.2 


159.0 


0.6 


Chronic liver disease and cirrhosis 


54.2 


12.2 


11.1 


20.1 


4.4 


Homicide 


25.5 


10.4 


6.5 


36.0 


2.5 


Pneumonia and influenza 


23.1 


11.4 


10.7 


16.1 


2.0 


Diabetes mellitus 


22.8 


10.0 


9.0 


18.5 


2.3 


Suicide 


21.8 


11.9 


12.4 


7.9 


1.8 


Tuberculosis, all forms 


4.4 


0.7 


0.4 


2.5 


6.3 


Chronic obstructive pulmonary 












diseases and allied conditions 


8 7 


14.9 


15.3 


10.7 


0.6 



Source: Monthly Vital Statistics Report, NCHS, DHHS Pub. No. (PHS) 82-1120, vol. 31, No. 6. 

Taken from FY 1984 Budget Appropriation Indian Health Service "Chart Series" Tables. Vital Events Branch, Office of Program 
Statistics. Division of Resource Coordination Indian Health Service, Rockville, MD, November 1982 



40 



Table 16 

Ratio of age-adjusted death rates for the 1 5 leading causes of death, by sex and race: United States, 1 980 







Ratio of- 






Cause of death 






Rank 1 


(Ninth Revision International 


Male to 


Black to 




Classification of Diseases, 1975) 


female 


white 




All causes 


1.79 


1.50 


1 


Diseases of heart 


1 .99 


1 .29 


2 


Malignant neoplasms, including neoplasms of lymphatic 








and hpmatnnoipfir tissufis 


1 .51 


1 .32 


3 


Oprphrova^n ilar dispa^ps 


1.19 


1 .80 


4 


Arridpnts and advprsp pffpcts 


2.93 


1 .23 




Mntnr vphirlp arridpnts 


2.90 


0.84 




All other accidents and adverse effects 


2.96 


1 .75 


5 


Chronic nbstrurtivp nulmnnarv dispasps and allipd 








conditions 


2.93 


0.76 


6 


Pneumonia and influenza 


1 .77 


1.57 


7 


Diabetes mellitus 


1 .02 


2.23 


8 


Chronic liver disease and cirrhosis 


2.16 


1.96 


9 


Atherosclerosis 


1.32 


1.14 


10 


Suicide 


3.33 


0.52 


11 


Homicide and legal intervention 


3.86 


5.88 


12 


Certain conditions originating in the perinatal period 2 


1.27 


2.43 


13 


Nephritis, nephrotic syndrome, and nephrosis 


1.58 


3.21 


14 


Congenital anomalies 2 


1.16 


1.13 


15 


Septicemia 


1.45 


2.82 



1 Rank based on number of deaths, see Technical notes 

inasmuch as deaths from these causes occur mainly among infants, ratios are based on 1980 infant mortality rates instead of 
rates adjusted to the total population of the United States in 1940. 

Source: National Center for Health Statistics: Advance report, final mortality statistics, 1980. Monthly Vital Statistics Report, Vol 
32 No. 4 Supp. DHHS Pub. No. (PHS) 83-1120. Public Health Service, Hyattsville, MD, August 1983 Table C, p 6 



Table 17 

Average length of life in years, by race and sex: United States, specified years, 1950-82. 

[For 1981 and 1982, based on a 10-percent sample of deaths; for all other years, based on final data.] 



All other 



Year 




All races 




White 






Total 






Black 




Both 
sexes 


Male 


Female 


Both 

sexes 


Male 


Female 


Both 
sexes 


Male 


Female 


Both 
sexes 


Male 


Female 


1982(est.) 


74.5 


70.8 


78.2 


75.1 


71.4 


78.7 


70.9 


66.5 


75.2 


69.3 


64.8 


73.8 


1981 (est.) 


74.1 


70.3 


77.9 


74.7 


71.0 


78.5 


70.3 


66.1 


74.5 








1980 


73.7 


70.0 


77.5 


74.4 


70.7 


78.1 


69.5 


65.3 


73.6 


68.0 


63.7 


72.3 


1979 


73.9 


70.0 


77.8 


74.6 


70.8 


78.4 


69.8 


65.4 


74.1 


68.5 


64.0 


72.9 


1978 


73.5 


69.6 


77.3 


74.1 


70.4 


78.0 


69.3 


65.0 


73.5 


68.1 


63.7 


72.4 


1977 


73.3 


69.5 


77.2 


74.0 


70.2 


77.9 


68.9 


64.7 


73.2 


67.7 


63.4 


72.0 


1976 


72.9 


69.1 


76.8 


73.6 


69.9 


77.5 


68.4 


64.2 


72.7 


67.2 


62.9 


71.6 


1975 


72.6 


68.8 


76.6 


73.4 


69.5 


77.3 


68.0 


63.7 


72.4 


66.8 


62.4 


71.3 


1970 


70.8 


67.1 


74.7 


71.7 


68.0 


75.6 


65.3 


61.3 


69.4 


64.1 


60.0 


68.3 


1960 


69.7 


66.6 


73.1 


70.6 


67.4 


74.1 


63.6 


61.1 


66.3 








1950 


68.2 


65.6 


71.1 


69.1 


66.5 


72.2 


60 8 


59.1 


62.9 









Source: National Center for Health Statistics: Annual summary of births, deaths, marriages, and divorces: United States, 1982 Mon- 
thly Vital Statistics Report, Vol 31, No. 13 DHHS Pub. No. (PHS) 83-1120. Public Health Service. Hyattsville, MD., October 1983, 
Table 5, p 15 



41 



Table 18 

Life expectancy at various ages by race and sex: United States, 1976. 



Age (years) 




Whites 






Nonwhites 




Both sexes 


Males 


Females 


Both sexes 


Males 


Females 


o 


74.0 


70.2 


77.8 


69.2 


65.0 


73.6 


10 


65.1 


61 .5 


68.9 


61 .1 


57.0 


65.4 


20 


55.5 


52.0 


59.1 


51 .5 


47.4 


55.6 


30 


46.2 


42.8 


49.5 


42.5 


38.8 


46.2 


40 


36.7 


33.6 


39.9 


33.7 


30.4 


37.0 


50 


27.8 


24.8 


30.7 


25.7 


22.8 


28.5 




91 7 


?n r 

c.\J .O 




99 1 


1 C7 . O 


94 7 


60 


19.8 


17.2 


22.3 


18.9 


16.5 


21.2 


65 


16.4 


14.0 


18.4 


16.1 


14.1 


18.0 


70 


13.1 


11.1 


14.8 


13.2 


11.6 


14.8 


75 


10.3 


8.6 


11.5 


11.2 


9.8 


12.5 


80 


8.0 


6.7 


8.8 


10.3 


8.8 


11.5 


85 


6.2 


5.3 


6.7 


9.3 


7.8 


9.9 



Source: National Center for Health Statistics: Life Tables: Vital Statistics of the United States, 1978. Vol. I, sec. 5, U.S. Government 
Printing Office, Washington. DC, 1980, p. 13. Taken from Markides, Kyriakos, "Mortality Among Minority Populations A Review 
of Recent Patterns and Trends." Public Health Reports, 252-260, May-June 1983. Table 1, p. 253. 



42 



Table 19 

Marital status of the population, by sex: 1940 to 1981. 

(In millions, except percent, 1940-60, persons 14 years old and over; thereafter, 18 and over. As of March, except as noted. Prior 
to 1960, excludes Alaska and Hawaii. Beginning 1950, based on Current Population Survey and excludes Armed Forces except 
those living off post or with their families on post. See Historical Statistics, Colonial Times to 1970, series A 160-171 , for decennial data) 



Sex and Marital Status 


1940' 


1950 


1960 


1970 


1980' 


1980 3 


1981 


Tntal 


1 m 1 


1117 




1 ft? ^ 


1 ^fi ? 




1 fi? 1 


Single 


31.5 


25.5 


27.7 


21.4 


31.4 


32.3 


33.2 


Married 


60.3 


74.9 


84.4 


95.0 


102.6 


104.6 


105.3 


Widowed 


7.8 


9.3 


10.6 


11.8 


12.5 


12.7 


12.8 


Divorced 


1.4 


2.1 


2.9 


4.3 


9.7 


9.9 


10.8 


Porront r\f total 


1 on n 

I UU.U 


1 nn n 


1 nn n 


1 nn n 

I uu.u 


1 nn n 

I uu.u 


1 nn n 

I uu.u 


mn n 

I uu.u 


Single 


31.2 


22.8 


22.0 


16.2 


20.1 


20.3 


20.5 


Married 


59.6 


67.0 


67.3 


71.7 


65.7 


65.5 


64.9 


Widowed 


7.8 


8.3 


8.4 


8.9 


8.0 


8.0 


7.9 


Divorced 


1.4 


1.9 


2.3 


3.2 


6.2 


6.2 


6.7 


KA oloc total 

Ivldicb, LUldi 


^n fi 

uu.u 


^4 ft 


fin fi 

uu.u 


fi? R 


74 1 

/ H . I 


/ u . / 


7K Q 

/ U. C7 


Single 


17.6 


14.3 


15.4 


11.8 


17.4 


18.0 


18.4 


Married 


30.2 


37.2 


41.8 


47.1 


50.8 


51.8 


52.1 


Widowed 


2.1 


2.3 


2.3 


2.1 


2.0 


2.0 


1.9 


Divorced 


.6 


.9 


1.1 


1.6 


3.9 


3.9 


4.4 


Pproont f"if tnt^l 


1 on n 

I uu . u 


1 nn n 
i uu.u 


1 nn n 

I uu.u 


1 nn n 

I uu.u 


1 nn n 

I uu.u 


1 nn n 

I uu.u 


1 nn n 

I uu.u 


Single 


34.8 


26.2 


25.3 


18.9 


23.5 


23.8 


23.9 


Married 


59.7 


68.0 


69.1 


75.3 


68.6 


68.4 


67.8 


Widowed 


4.2 


4.2 


3.7 


3.3 


2.7 


2.6 


2.5 


Divorced 


1.2 


1.7 


1.9 


2.5 


5.2 


5.2 


5.7 


rciOfc?lll oLcti lUcif Uizt;U iui dye 
















Single 


30.7 


26.2 


25.3 


16.5 


18.7 


18.7 


18.9 


Married 


62.6 


67.4 


69.1 


77.6 


72.8 


72.9 


72.3 


Widowed 


5.4 


4.7 


3.7 


3.3 


2.8 


2.7 


2.7 


Divorced 


1.3 


1.7 


1.9 


2.6 


5.6 


5.6 


6.2 


Pom ol DC totQ I 


JU. J 


o / .u 




7n n 
/ u.u 


R9 1 
Oc.. I 


oo,o 




Single 


13.9 


ii.i 


12.3 


9.6 


14.0 


14.3 


14.8 


Married 


30.1 


37.6 


42.6 


47.9 


51.8 


52.8 


53.2 


Widowed 


5.7 


7.0 


8.3 


9.7 


10.5 


10.8 


10.9 


Divorced 


.8 


1.2 


1.7 


2.7 


5.8 


6.0 


6.4 




1 no n 


1 on n 

i uu. u 


1 nn n 
I uu.u 


1 nn n 


1 nn n 
I uu.u 


1 nn n 
I uu.u 


1 nn n 
I uu.u 


Single 


27.6 


19.6 


19.0 


13.7 


17.0 


17.1 


17.4 


Married 


59.5 


66.1 


65.6 


68.5 


63.1 


63.0 


62.4 


Widowed 


11.3 


12.2 


12.8 


13.9 


12.8 


12.8 


12.7 


Divorced 


1.6 


2.2 


2.6 


3.9 


7.1 


7.1 


7.6 


Percent standardized for age 4 
















Single 


24.2 


20.0 


19.0 


12.1 


14.5 


14.5 


14.8 


Married 


59.3 


63.9 


65.6 


70.8 


65.9 


65.9 


65.3 


Widowed . . ■. 


14.8 


14.0 


12.8 


13.0 


12.0 


12.1 


11.9 


Divorced 


1.6 


2.1 


2.6 


4.1 


7.6 


7.6 


8.1 



1 As of April. Population controls based on 1970 census. Population controls based on 1960 census. 

4 1960 age distribution used as standard; standardization improves comparability over time by removing effects of changes in age 

distribution of population. 

Source: U.S. Bureau of the Census U S Census of Population: 1950, Vol. II, Part 1 . and Current Population Reports, Series P-20. 
No. 372 and earlier reports. Taken from Statistical Abstract of the U.S. 1982-83 U.S. Government Printing Office, Washington, 
DC, December 1982, Table 47, p, 38. 



Table 20 

Marital status of the black and Spanish Origin population: 1960 to 1981. 

[Black population: 1960 and 1965, persons 14 years old and over, thereafter 18 and over. Spanish origin population: 1970 and 
1975, persons 14 years old and over, thereafter, 15 and over Except as noted, as of March and based on Current Population 
Survey, which includes members of Armed Forces living off post or with their families on post, but excludes all other members 
of Armed Forces] 



Sex and Year 



Number of Persons (1,000) 



Percent Distribution 



Total Single Married Widowed Divorced Total Single Married Widowed Divorced 



Black 



I otal 


1 960 1 




1965 




1970 




1975 




1980 2 




1 QR1 

I JO I 


Male: 


I960 1 




1965 




1970 




1975 




19802 




1981 


Female: 


I960 1 




1965 




1970 




1975 




19802 




1981 



Spanish Origin 3 



Total: 3 



Male: 



Female: 



1970 1 

1975 

1980 2 

1981 

1970 1 

1975 

19802 

1 981 4 

Mexican 

Puerto Rican 

1970 1 

1975 

1 9802 

1 981 4 

Mexican .... 

Puerto Rican 



12,088 


3,078 


7,461 


1 ,1 74 


376 


100.0 


25.5 


61 .7 


9.7 


3.1 


13,273 


3,601 


7,996 


1 ,194 


482 


100.0 


27.1 


60.2 


9.0 


3.6 


12,972 


2,668 


8,310 


1 ,427 


567 


100.0 


20.6 


64.1 


1 1 .0 


4.4 


14,262 


3,449 


8,373 


1 ,521 


920 


100.0 


24.2 


58.7 


10.7 


6.5 


16,638 


5,070 


8,545 


1 ,627 


1 ,396 


100.0 


30.5 


51 .4 


9.8 


8.4 


17,041 


5,229 


8,601 


1,616 


1,594 


100.0 


30.7 


50.5 


9.5 


9.4 


5,713 


1,692 


3,619 


264 


139 


100.0 


29.6 


63.3 


4.6 


2.4 


6,211 


1,980 


3,795 


245 


191 


100.0 


31.9 


61.1 


3.9 


3.1 


5,898 


1,435 


3,944 


307 


212 


100.0 


24.3 


66.9 


5.2 


3.6 


6,368 


1,733 


3,990 


319 


327 


100.0 


27.2 


62.7 


5.0 


5.1 


7,416 


2,540 


4,051 


308 


517 


100.0 


34.3 


54.6 


4.2 


7.0 


( ,oyu 


^,bUb 


4,Uoo 


ouy 


DlO 


\ uu.u 


ia i 


OO.O 


4.1 


O. 1 


6,375 


1,386 


3,842 


910 


237 


100.0 


21.7 


60.3 


14.3 


3.7 


7,062 


1,621 


4,201 


949 


291 


100.0 


23.0 


59.5 


13.4 


4.1 


7,074 


1,233 


4,366 


1,120 


355 


100.0 


17.4 


61.7 


15.8 


5.0 


7,894 


1,716 


4,383 


1,202 


593 


100.0 


21.7 


55.5 


15.2 


7.5 


9,222 


2,530 


4,494 


1,319 


878 


100.0 


27.4 


48.7 


14.3 


9.5 


y,4ol 




A E.A A 

4,c>44 


I ,oUi 


y i b 


\ UU.U 


07 Q 


A Q 1 

4o. 1 


1 O Q 
\ O.O 


l U.o 


5,872 


1 ,718 


3,666 


267 


201 


100.0 


29.3 


62.4 


4.9 


3.4 


7,264 


2,293 


4,378 


296 


296 


100.0 


31 .6 


60.3 


4.1 


4.1 


8,697 


2,683 


5,202 


350 


461 


100.0 


30.8 


59.8 


4.0 


5.3 


9,163 


2,738 


5,530 


354 


541 


100.0 


29.9 


60.4 


3.9 


5.9 


2,838 


914 


1,801 


56 


67 


100.0 


32.2 


63.5 


2.0 


2.3 


3,520 


1,277 


2,103 


42 


96 


100.0 


36.3 


59.7 


1.2 


2.8 


4,196 


1,439 


2,546 


60 


151 


100.0 


34.3 


60.7 


1.4 


3.6 


4,429 


1,506 


2,672 


71 


178 


100.0 


34.0 


60.3 


1.6 


4.0 


2,738 


937 


1,647 


46 


109 


100.0 


34.2 


60.1 


1.7 


4.0 


465 


172 


262 


11 


20 


100.0 


37.1 


56.4 


2.3 


4.2 


3,033 


804 


1,864 


231 


134 


100.0 


26.5 


61.5 


7.6 


4.4 


3,744 


1,016 


2,275 


256 


196 


100.0 


27.1 


60.8 


6.8 


5.3 


4,501 


1,244 


2,656 


291 


310 


100.0 


27.6 


59.0 


6.5 


6.9 


4,734 


1,230 


2,858 


283 


363 


100.0 


26.0 


60.4 


6.0 


7.7 


2,743 


725 


1,686 


151 


180 


100.0 


26.4 


61.5 


5.5 


6.6 


635 


209 


333 


31 


62 


100.0 


32.9 


52.4 


4.9 


9.8 



'As of April. Population controls based on 1980 census, see text p. 2. 3 Persons of Spanish origin may be of any 
race 4 lncludes persons of Cuban, Central or South American, and other Spanish origin, not shown separately 
Source: U S Bureau of the Census. U.S. Census of Population 1960, PC(2) 1C. Nonwhite Population by Race and 1970, PC(2) 
1C. Persons of Spanish Origin: Current Population Reports, Series P-20. No. 372 and earlier issues and unpublished data. Taken 
from U.S. Bureau of the Census, Statistical Abstract of the United States: 1982-83 U.S. Government Printing Office, Washington, 
DC, December 1982, Table 48, p 39 



44 



Table 21 

Percent married and divorced of the population, 18 years old and over: 1960 to 1981. 

[As of March, Based on Current Population Survey and excludes Armed Forces except those living off post or with families on post.] 

Sex and Race 1960 1965 1970* 1974 1975 1976 1977 1978 1979 1980 1 1980 2 1981 



Percent married: 

Male 76.4 

White 77.3 

Black and other 66.4 

Female 71 .6 

White 72.2 

Black and other 66.3 

Percent divorced: 

Male 2.0 

White 2.0 

Black and other 2.2 

Female 2.9 

White 2.7 

Black and other 4.8 



76.2 


75.3 


73.7 


72.8 


72.2 


70.9 


76.9 


76.1 


74.9 


73.9 


73.4 


72.3 


70.2 


65.4 


63.1 


63.5 


62.0 


60.6 


70.5 


68.5 


67.6 


66.7 


66.2 


65.3 


70.9 


69.3 


68.8 


68.0 


67.6 


66.7 


67.6 


62.6 


58.9 


57.3 


56.2 


55.4 


2.5 


2.5 


3.5 


3.7 


4.0 


4.5 


2.4 


2.4 


3.3 


3.6 


3.8 


4.4 


3.4 


3.4 


4.8 


4.6 


5.5 


5.0 


3.3 


3.9 


4.9 


5.3 


5.7 


6.2 


3.1 


3.8 


4.7 


5.0 


5.5 


6.0 


4.5 


4.8 


6.3 


7.1 


7.4 


8.2 



70.1 


69.2 


68.6 


68.4 


67.8 


71.7 


70.7 


70.1 


70.0 


69.6 


58.4 


57.5 


57.1 


56.3 


55.2 


64.2 


63.5 


63.1 


63.0 


62.4 


65.9 


65.2 


64.8 


64.7 


64.1 


52.6 


51.8 


51.5 


51.6 


50.9 



4.7 


4.8 


5.2 


5.2 


5.7 


4.5 


4.5 


5.0 


5.0 


5.5 


6.3 


6.6 


6.6 


6.4 


7.0 


6.6 


6.6 


7.1 


7.1 


7.6 


6.3 


6.4 


6.8 


6.8 


7.2 


8.8 


8.3 


8.9 


8.8 


9.6 



Population controls based on 1970 census. 2 Populaton controls based on 1980 census. 

Source: U.S. Bureau of the Census, Statistical Abstract of the United States- 1982-83 U.S. Government Printing Office, Washington, 
DC, December 1982, Table 52, p. 41. 



References 

1. Godley, Frank, and 
Wilson, Ronald W. "Health 
Status of Minority Groups" In 
Health: United States, 1979. 
National Center for Health 
Statistics, Office of Health 
Research, Statistics, and 
Technology, Public Health 
Service. U.S. Department of 
Health, Education, and 
Welfare. DHEW Pub. No. 
(PHS) 80-1232, U.S. Govern- 
ment Printing Office, 1980. 

2. U.S. Bureau of the Cen- 
sus, Statistical Abstract of the 
United States: 1982-83. U.S. 
Government Printing Office, 
Washington, DC, December 
1982. 

3. National Center for Health 
Statistics, S.J. Ventura: Births 
of Hispanic Parentage, 1980. 
Monthly Vital Statistics 
Report, Vol. 32, No. 6 Supp. 
DHHS Pub. No. (PHS) 
83-1120. Public Health Serv- 
ice, Hyattsville, MD, 
September 1983. 

4. Kitagawa, E.M, and 
Hauser, P.: Differential Mor- 
tality in the United States: A 
Study in Socioeconomic 
Epidemiology, Harvard 
University Press, Cambridge, 
MA, 1973. 

5. Hakama, Matti, Hakulinen, 
Timo, Pukkala, Ero, Saxen, 
Erkki and Teppo, Lyly: "Risk 
Indicators of Breast and Cer- 
vical Cancer on Ecologic and 
Individual Levels" American 
Journal of Epidemiology. Vol. 
116, No. 6, 1982, pp. 
990-1000. 

6. Paffenbargers, R.S., 
Kampert, J.B., and Chang, 
H.G. "Characteristics that 
predict risk of breast cancer 
before and after the 
menopause" American Jour- 
nal of Epidemiology. August 
Vol. 112, No. 2, 1980, pp. 
258-268. 



7. National Center for Health 
Statistics: Annual summary of 
births, deaths, marriages, 
and divorces: United States, 
1982. Monthly Vital Statistics 
Report, Vol. 31, No. 13. 
DHHS Pub. No. (PHS) 
83-1120. Public Health Serv- 
ice, Hyattsville, MD, October 
1983. 

8. Public Health Service, 
U.S. Department of Health 
and Human Services: Health: 
United States, 1982. DHHS 
Pub. No. (PHS) 83-1232, 
U.S. Government Printing Of- 
fice, Washington, DC, 1982. 

9. National Center for Health 
Statistics: Advance report, 
final mortality statistics, 1980. 
Monthly Vital Statistics 
Report, Vol. 32, No. 4 Supp. 
DHHS Pub. No. (PHS) 
83-1120. Public Health Serv- 
ice, Hyattsville, MD, August 
1983. 

10. Markides, Kyriakos "Mor- 
tality Among Minority Popula- 
tions: A Review of Recent 
Patterns and Trends. Public 
Health Reports, 252-260, 
May-June 1983. 

11. Manton, K.G. "Sex and 
race specific differentials in 
multiple cause of death 
data." Gerontologist 20: 
480-493 (1980) 

12. National Center for 
Health Statistics, J. A. Weed: 
National Estimates of Mar- 
riage Dissolution and Sur- 
vivorship: United States. Vital 
and Health Statistics, Series 
3, No. 19. DHHS Pub. No. 
(PHS) 81-1403. Hyattsville, 
MD, U.S. Government Print- 
ing Office, November 1980. 



List of Tables 

1. Resident population, by 
race and Spanish origin, by 
State: 1980. 

2. Resident population, by 
age, sex, and race: 
1970-1980. 

3. Spanish-origin population, 
by age and sex: 1980. 

4. Number and percent 
distribution of the total 
American Indian and Alaska 
Native population for reserva- 
tion States and U.S. All races 
by age, 1980 census data. 

5. Social and economic 
characteristics of population, 
by race and Spanish origin: 
1980. 

6. Persons below poverty 
level, by age, region, race, 
and Spanish origin: 1981. 

7. Live births, birth rates, 
and fertility rates, by race of 
child: United States, specified 
years 1940-60 and each year 
1965-1980. 

8. Birth rates by Hispanic 
origin of mother, and by race 
of child for mothers of non- 
Hispanic origin: 22 reporting 
States, 1980. 

9. Number and rate of live 
births for Indians and Alaska 
Natives in reservation States, 
and U.S. All races, 
1954-1979. 

10. Fertility rates by Hispanic 
origin of mother, and by race 
of child for mothers of non- 
Hispanic origin: 22 reporting 
States, 1980. 

11. Total fertility rate and in- 
trinsic rate of natural in- 
crease: 1940-1979. 

12. Unwanted births of all 
mothers, 15-44 years old: 
1973 and 1976. 

13. Contraceptive use by 
currently married women 
15-44 years old, by age, 
race, and method of con- 
traception: 1965 to 1976. 



14. Age-adjusted death rates 
by race and sex: death 
registration States, selected 
years 1900-1930, and United 
States selected years 
1940-1980. 

15. Age-adjusted mortality 
rates, American Indians and 
Alaska Natives in reservation 
States and selected U.S. 
populations by race, 1979. 

16. Ratio of age-adjusted 
death rates for the 15 leading 
causes of death, by sex and 
race: United States, 1980. 

17. Average length of life in 
years, by race and sex: 
United States, specified 
years, 1950-82. 

18. Life expectancy at 
various ages by race and 
sex: United States, 1978. 

19. Marital status of the 
population, by sex: 1940 to 
1981. 

20. Marital status of the 
black and Hispanic-Origin 
population: 1960 to 1981. 

21. Percent married and 
divorced of the population, 
18 years old and over: 1960 
to 1981. 

List of Figures 

1. Map of the U.S., showing 
census divisions and regions. 

2. Age-adjusted mortality 
rates by race and sex: U.S., 
1935-1980. 

3. Age-adjusted death rates 
for 13 of the 15 leading 
causes of death: 1950-80. 



46 



Chapter III 



Problems of Reproductive Health 
and Genetic Disease 



Table of Contents 



Overview 49 

A. Introduction 50 

B. The Measures ot Reproductive Health Status 50 

1 . Maternal Mortality and Morbidity 50 

2. Infant and Fetal Mortality 52 

3. Factors Associated with Infant Mortality and 
Morbidity 54 

a. Low Birthweight 54 

b. Mother's Age, Parity, and Marital Status 56 

c. Socioeconomic Factors and Medical 
Care 56 

4. The Problems of Unwanted Fertility and Infertility 57 

C. Sexually Transmitted Diseases (STD's) 58 

1. Syphilis 59 

2. Gonorrhea 60 

3. Herpes II 61 

4. Acquired Immunodeficiency Syndrome 
(AIDS) 61 

D. Mental Retardation 62 

E. Selected Genetic Diseases 63 
Tables 64 

References 83 
List of Tables 84 
List of Figures 85 



47 



Chapter III 



Problems of Reproductive Health 
and Genetic Disease 



Overview 

In this chapter, the health 
status of various minorities is 
compared with that of the 
white majority and the 
general population with 
regard to conditions 
associated with reproduction 
and genetic problems. More 
specifically, this chapter ex- 
amines health status 
measures related to preg- 
nancy and childbearing and 
to sexually transmitted 
diseases. It also discusses a 
selected group of genetic 
problems and cites progress 
in dealing with some of 
these. 

Maternal mortality has 
declined over 98 percent in 
the United States in the 50 
years from 1930 to 1980, but 
further reductions are 
needed, especially for blacks, 
American Indians, and Alaska 
Natives, to achieve the 1990 
national goals for maternal 
mortality. The mothers of 
other-than-white races had a 
mortality rate of 19.8 per 
100,000 live births, almost 
three times that of white 
mothers and over twice that 
of the total population in 
1980. The 1980 black mater- 
nal mortality rate of 21.5 was 
the major component of this 
group rate and was the 
highest rate of all minorities. 
The 1978 maternal mortality 
rate of American In- 
dians/Alaska Natives (11.1) 
was 16 percent higher than 
that of the total population 
that year. 

The infant mortality rate in 
the United States continues 
to decline (48 percent from 
1960 to 1980). Here again, 
while the rates of all racial 
groups have improved, 
blacks still had almost twice 



the infant mortality rate of 
whites (11.0), and the black 
infant mortality rate (21.4) 
was also significantly higher 
than the rate for the entire 
population (12.6) in 1980. In 
1978, the infant mortality rate 
of American Indians/Alaska 
Natives was 1 1 percent 
higher than that of the total 
population. Between 1970 
and 1978, the racial differen- 
tial between American In- 
dians/Alaska Natives and the 
total population narrowed 
from 2.07 to 1 .29. Between 
1970 and 1981 , the mortality 
rate differential has changed 
very little between blacks and 
the total population. Whites 
and Asians seem already to 
have achieved 1990 goals for 
infant mortality rates on a na- 
tional level, but even these 
groups need to improve rates 
in many smaller areas. Rates 
of other races, especialy 
blacks, require major reduc- 
tions if the goals are to be 
achieved. 

Low birthweight (under 
2,500 grams) is another im- 
portant health status 
measure. A low birthweight 
infant has a greater risk of in- 
fant mortality and various 
kinds of morbidity. The pro- 
portion of low birthweight in- 
fants born to blacks is still 
about twice the proportion of 
those born to whites. Several 
other characteristics of the 
mother and the newborn in- 
fant are known to be related 
to increased risk of infant 
mortality and morbidity. 
Young mothers, older 
mothers, high parity mothers, 
and unmarried mothers all 
have higher incidences of 
poor reproductive 
outcomes— maternal, infant, 
and fetal mortality, low birth- 
weight infants— and in- 
creased levels of morbidity in 
their infants. Blacks have 



higher proportions in each of 
these risk groups than whites 
or any other race group. 
Socioeconomic status, as 
measured by educational at- 
tainment of the mother, ap- 
pears to be one of the best 
predictors of birthweight; 
birthweight increases with 
socioeconomic level. Again, a 
higher proportion of blacks 
than whites is found in the 
groups with lower levels of 
education (lower socio- 
economic levels). 

The number of prenatal 
care visits and the time of 
start of medical care received 
by the mother also contribute 
to the outcome of pregnancy. 
While a higher proportion of 
black women now start 
prenatal care in the first 
trimester than was the case 
in the past, a lower propor- 
tion of black women received 
early care than did white 
women. Also, in 1980 pro- 
portionately more black 
women received no prenatal 
care than was the case for 
white women. Relative to 
their population distribution, 
black women are higher 
utilizers of public family plan- 
ning clinics than white 
women, although this does 
not include all privately pro- 
vided services. Black women 
undergo proportionately 
fewer legal abortions than 
white women. The increase in 
abortion rates between 1973 
and 1980, however, was 
greater among black women 
than white women. 

The incidence of sexually 
transmitted diseases (STD's) 
has reached epidemic pro- 
portions in the United States. 
Four of these STD's are 
discussed briefly. The most 
striking change in the in- 
cidence of syphilis has been 
the large increase in in- 
cidence among white males. 



This increase has resulted in 
a reduction of the male race 
differential (other races/white) 
for attack rates and in an in- 
crease in the sex differential 
(male/female) for this disease. 
While the incidence of 
syphilis remains considerably 
higher among other races 
than among whites, the racial 
differential is decreasing 
primarily because of in- 
creases in the white race 
rates, so to interpret this as a 
measure of gain in the health 
status of other races would 
be incorrect. The incidence 
of syphilis is also higher 
among American In- 
dians/Alaska Natives than 
among whites. 

Racial differentials with 
regard to gonorrhea are also 
lower now than previously. 
This reflects, in small part, 
slight reductions in gonorrhea 
in males of nonwhite races, 
but stems primarily from 
large increases among white 
males and very large in- 
creases among white females 
between 1967 and 1979. The 
rates and racial differentials 
for two other sexually trans- 
mitted diseases with increas- 
ing prevalence, herpes II and 
acquired immunodeficiency 
syndrome (AIDS), cannot be 
determined. The difficulty 
arises because herpes II is 
not a reportable com- 
municable disease and AIDS 
is a newly identified problem. 

Mental retardation is a 
state of impairment— not a 
disease, but a syndrome or a 
symptom— which can stem 
from many causes, including 
psychosocial or polygenic in- 
fluences as well as biological 
deficits. A major factor 



49 



related to reproductive health 
and genetic disease is that 
prevention of mental retarda- 
tion is now possible in a 
number of circumstances. 
Also, better nutrition status of 
the mother and the infant 
support optimal physical and 
mental development of the in- 
fant. Tests for genetic defects 
and early identification and 
treatment of some problems 
are helping to correct prob- 
lems and ameliorate their 
former impact on the infant, 
including mental retardation. 

With respect to 
racial/ethnic differences in the 
incidence of genetic 
disorders, some of the in- 
herited diseases are linked to 
specific racial/ethnic groups. 
Sickle cell anemia affects 
primarily blacks, while cystic 
fibrosis occurs mostly among 
whites. Tay-Sachs disease is 
mostly limited to Jews of 
Eastern European origin, 
while thalassemia has a 
relatively high incidence 
among people from the 
Mediterranean countries and 
Pacific Islands, and 
phenylketonuria (PKU) is 
more prevalent among peo- 
ple of European descent. It is 
now possible to determine 
carriers of some genetic 
defects so that informed deci- 
sions can be made about 
whether or not to have a 
child. It is also possible now 
to diagnose whether a fetus 
has various problems so 
parents may consider alter- 
natives. Early identification 
and treatment of some inborn 
errors of metabolism can 
correct the problem or 
ameliorate its impact on the 
infant. PKU tests are con- 
ducted for almost all 
newborns. Solutions for other 
metabolic problems are be- 
ing tested in a growing 
number of States; other 



genetic problems can be 
reduced or controlled by 
drugs or other treatments. 
A. Introduction 

In this chapter, selected 
health problems related to 
reproduction are discussed. 
Section B contains informa- 
tion derived from analyses of 
vital records data describing 
reproductive events. Health 
status measures from this 
source include maternal, in- 
fant, and fetal mortality data, 
and low birthweight informa- 
tion from natality data. It is 
possible to relate these data 
directly to race and minority 
ethnic populations. Death 
records provide information 
about cause, age at death, 
and race of the deceased. 
Birth records provide informa- 
tion about the mother (race, 
age, marital status, education 
level), the infant (race and 
birthweight), the pattern of 
care (when care started, 
number of visits, site/atten- 
dant at birth), and other 
characteristics of the birth 
event (parity, length of gesta- 
tion, interval since the last 
birth). Analyses of subgroups 
using such descriptors as 
race, education level of the 
mother, mother's age, and 
marital status have shown 
that some categories within 
the subgroups have a larger 
proportion with poor outcome 
measures. 

An indirect relationship to 
poverty also has been de- 
fined, since the groups with 
greater proportions of poor 
outcome measures are also 
often residents of areas 
where relatively large portions 
of the population have low in- 
come levels. Education level 
of the mother is also often 
used as a proxy to measure 
economic status. In some 



cases, the racial or ethnic 
groups with larger propor- 
tions of poor outcomes also 
have relatively large propor- 
tions with low income. 
Because of these relation- 
ships, such groups (e.g., 
mothers with low education 
levels, very young mothers, 
or black mothers) have been 
used as proxy indicators of 
disadvantaged groups in the 
population. Also covered in 
Section B are other subjects 
related to reproduction: family 
planning (use of contracep- 
tion and treatment of 
infertility) and abortion. 

Material about sexually 
transmitted diseases is in- 
cluded in Section C because 
these diseases— with their 
adverse impact on the health 
of fathers, mothers, and 
infants— are transmitted via 
the process of reproduction. 
The last sections deal with 
mental retardation and 
selected inherited and 
genetic defects. 

The incidence and/or 
prevalence of problems 
related to acute and chronic 
conditions which may also af- 
fect reproduction (e.g., 
cancer of the reproductive 
organs) are not covered in 
this chapter. They are 
discussed in the chapters 
dealing with these general 
conditions. 

Chapter I presents many 
caveats about interpreting the 
information in this publication. 
These are of special impor- 
tance to users of this chapter. 
In addition, because of the 
availability of the many 
statistical analyses using vital 
records data, the reader 
should understand that the 
statistical relationships of 
various population 
characteristics to poor health 
status measures are not 
necessarily causal relation- 



ships. For example, while 
black mothers have a higher 
proportion of poor reproduc- 
tive outcomes than white 
mothers, being black does 
not cause a poor outcome 
and being white does not 
prevent one. In fact, mothers 
of all races with similar high- 
risk characteristics have a 
higher proportion of poor out- 
comes (e.g., the very young, 
the unwed, those with low 
education levels, those with 
poor patterns of care or no 
care). 

B. The Measures of 
Reproductive Health 
Status 

1. Maternal Mortality and 
Morbidity 

Throughout history until the 
last 50 years, the reproduc- 
tive process— pregnancy, 
delivery, and aftercare of the 
mother— has taken a terrible 
toll in maternal deaths. At the 
beginning of this century, 
more than 7 out of each 100 
mothers died during or as a 
result of childbearing, and 
the rates changed little until 
the mid 1930's (see Table 1). 
After more careful instruction 
of the mother, improved 
prenatal care, more stringent 
observance of hygiene dur- 
ing confinement, and other 
measures to make childbear- 
ing safer, the rates began to 
drop rapidly (1 , p. 509). 
Some of the reductions that 
occurred from the 1940's on 
were thought to be due to in- 
vestigations into the causes 
of maternal deaths, major 
changes (stemming from 
these investigations) in pro- 
viding care, and the introduc- 
tion of effective drugs to 
combat infection (2, p. 86). 
More recent reductions in 
maternal mortality stem from 



50 



further improvement in and 
more widespread utilization of 
these practices, various 
technical advances, the 
availability of family planning 
to allow better spacing of 
pregnancies, and legal abor- 
tions, which have ". . .per- 
mitted terminations of 
pregnancy when conditions 
were less than 
favorable. ..." (1, p. 507) 

The maternal mortality rate 
declined from 673.2 per 
100,000 live births in 1930 to 
9.2 (339 deaths) in 1980, a 
staggering 98.6 percent drop 
during a 50-year period. The 
rate was reduced still further 
in 1981 to 8.6 per 100,000 
women (see Table 1). The 
50-year reduction was 
reflected in rates of both the 
white group (98.9 percent) 
and the "other races" group 
(98.3 percent). In the 1930's 
and 1940's, the percent 
reductions were much 
greater for the white race. 
This was reflected in an in- 
creasing differential of over 
three and a half times higher 
mortality for mothers of other 
races. In the 1950's and 
1960's, the percent reduc- 
tions were almost the same, 
and in the 1970's, the per- 
cent reduction for the other 
races was substantially 
greater than for whites. 
Despite this rate of improve- 
ment, the maternal mortality 
rate for nonwhites is still 
almost three times that of 
white mothers, 19.8 versus 
6.7 per 100,000 live births in 
1980. The basic reduction 
continued in 1981, when the 
white maternal mortality rate 
was 6.3 and the nonwhite 
rate was 17.3 per 100,000 
live births, leading to a fur- 
ther reduction of the differen- 
tial to 2.75. 



The largest component of 
the nonwhite population is 
the black race, comprising 
11.7 percent of the 1980 
U.S. population and 16.3 
percent of 1980 U.S. live 
births. The maternal death 
rates for this group are 
higher than those of the com- 
bined total for all other non- 
white groups, identifying 
black mothers as a group 
posing special problems in 
this area. 

Another important compo- 
nent of the nonwhite popula- 
tion, though substantially 
smaller in number than the 
black component, is 
American Indians/Alaska 
Natives, about 0.6 percent of 
the U.S. population in 1980. 
While the maternal mortality 
rate of this group was 
substantially better than that 
of blacks, it was at least 1 .5 
times higher than the white 
rate through 1973. During 
the next 5-year period 
(1974-1979), it was for 3 
years slightly better than for 
whites and for 2 years 
somewhat worse. 

The disparity between the 
nonwhite maternal mortality 
rate versus the white rate as 
of 1980 is also shown in the 
following: 



Race Group 

Total 
White 
Other 
(Black) 



Blacks fared proportion- 
ately worst of the racial 
groups for which data were 
available. Maternal mortality 
data on Asians were not 
analyzed because of the very 
small numbers involved. 



The four leading causes of 
maternal deaths in 1980 
were: 



Cause 

Complications of puerperium 
Toxemia of pregnancy 
Ectopic pregnancy 
Hemorrhage of pregnancy and 
childbearing 



The disadvantage for non- 
white mothers versus white 
mothers is true also of 
specific causes of death. Ec- 
topic pregnancy has a non- 
white death rate 4.25 times 
greater than the rate for white 
mothers. A contributor to ec- 
topic pregnancy, pelvic in- 
flammatory disease, has a 
much higher incidence 
among blacks than whites 
(see Chapter IV, Section C). 
This condition can also lead 
to infertility. 

Further reduction of mater- 
nal mortality rates is today a 
national objective. The 
specific goal from Promoting 
Health/Preventing Disease 
reads: "By 1990, the mater- 
nal mortality rate should not 
exceed 5 per 100,000 live 
births for any county or for 
any ethnic group (e.g., Black, 
Hispanic, American Indian)." 



Maternal Deaths (%) 

100 

58 

42 
(38) 



Nonwhite/White 
Differential 

2.05 
2.83 
4.25 

2.67 



(3, p. 17) To meet this goal, 
a reduction of 25 percent in 
the mortality rate of white 
mothers will need to occur 
between 1980 and 1990. Ob- 
viously, even greater reduc- 
tions are required among 
nonwhite mothers, especially 
black mothers, who need a 
reduction of over 75 percent. 
The reduction required 
among American In- 
dians/Alaska Natives between 
1978 and 1990 is 55 per- 
cent. While several programs 
directed at maternal health 
exist (4, pp. 31-32), 
" . . .studies have not 
generally been designed to 
yield firmly defensible data 
on the relative contribution of 
programs." (3, p. 17) 

Several risk factors are 
associated with maternal mor- 
tality and morbidity. "Women 
who are at particularly high 
risk during pregnancy are 
those with medical complica- 
tions such as heart disease 
or diabetes, those with a 
history of difficult pregnan- 
cies, and those who have 
had abortions or stillbirths." 
(1, p. 508) Whether or not 
they are serious enough to 
cause a maternal death, 
these problems adversely af- 
fect the health of the mother, 
the development of the fetus, 
and the health status of the 
newborn infant. The 
prevalence of diabetes is 
considerably higher among 



Population (%) 

100 
83 
17 
(11.6) 



51 



Figure 1 

Maternal death rates 

Per 100,000 
Live Births 



100 



75 



25 



0 



1958 


1960 


1965 


1970 


1975 


• 


.•* 






Indians and 














Alaska 










• 

• 

r. • 

• 




Natives 












• 

• 




U.S. Other 










• 

• • • 




than White 








U.S. All 




o 


e 








Races 






• •••• 
• • • • 

• 




i : 


I I I I 


I I I I 


I I I I 


• 

• 

I I I 



Source: FY 1984 Budget Appropriation Indian Health Service "Chart Series". Vital 
Events Branch, Office of Program Statistics, Division of Resource Coordination. Indian 
Health Service, Rockville, MD, April, 1983. 



nonwhite women than among 
white women (see Chapter V, 
Table 4). Also, the rate of 
fetal loss for nonwhite 
mothers, especially black 
mothers, is appreciably 
higher than for white mothers 
(see Table 5, this chapter). 
2. Infant and Fetal Mortality 

The infant mortality rate 
has conventionally been used 
both as an indicator of health 
status and as a measure of 
general living standards of a 
population. This rate is com- 
puted by dividing the number 
of infant deaths (deaths oc- 
curring during the first year 
of the infant's life) for a calen- 
dar year by the number of 
live births (in thousands) for 
that calendar year. Since the 
data are collected each year 
by the Vital Records System, 
the information is current and 
accurate. 

Use of this rate to 
measure health status is seen 
as preferable to use of mor- 
tality rates for the entire 
population, which are based 
on population estimates ex- 
cept in censal years. The 
health of the infant is in- 
fluenced both by the health 
of the mother and to some 
degree by the general health 
conditions of the environ- 
ment. Thus, the mortality and 
morbidity experience of in- 
fants may serve as a 
barometer of the general en- 
vironmental conditions that af- 
fect the health of the popula- 
tion. In fact, using infant mor- 
tality as a health status in- 
dicator has produced results 
remarkably close to those 
generated by far more com- 
plex formulas designed to 
measure an area's health 
status (2, p. 87). 

The infant mortality rate 
has the advantage of being 



simple to calculate and 
understand. It is also 
available for most other coun- 
tries, allowing comparisons. 
In addition, it is available for 
smaller geographical regions 
of the United States, for racial 
groups, and for other groups 
defined by such 
characteristics as mother's 
age, marital status, etc., 
which facilitates identification 
of both geographic areas 
and segments of the popula- 
tion requiring special 
attention. 

"Despite the belief of 
many Americans that the 
medical and health status of 
the United States population 
should be the best in the 
world, the basic health status 
measure, infant mortality, 
. . .does not reflect this ex- 
pectation." (2, p. 92) When 



the infant mortality rates of 20 
nations are ranked from low 
to high, the United States 
ranked 12th in 1976 and 
16th in 1980 (see Table 4). 
These nations were selected 
on the basis of " . . . eco- 
nomic development, size of 
population and certain report- 
ing constraints, as defined in 
World Health Organization 
Publications." (1, p. 92) 
While there are recording 
differences among some 
countries, the methods of 
defining and recording infant 
deaths in most developed 
countries are considered 
essentially comparable to 
those of the United States. 
Therefore it is generally ac- 
cepted that the United States 
does in fact lag behind a 
number of other countries in 
its ability to reduce infant 
deaths. This is explained by 
some as resulting from dif- 



ferences in demographic 
makeup, in the availability 
and accessibility of health 
care systems, and in socio- 
economic characteristics. 

Within the United States, 
infant mortality rates, like 
maternal mortality rates, vary 
among the various racial 
groups. In 1980, 12.6 out of 
every 1 ,000 infants, 1 1 .0 of 
every 1 ,000 white infants, 

19.1 of every 1,000 nonwhite 
• ("black and other") infants, 

and 21 .4 of every 1 ,000 
black infants born alive died 
in infancy (see Table 5). Thus 
the black infant mortality rate 
was almost twice the rate of 
whites in 1980 (see Table 5 
and Figure 2). 

The infant mortality rate of 
American Indians/Alaska 
Natives (see Table 6) was 

29.2 percent higher than that 
of whites in 1978: 15.5 infant 
deaths per 1 ,000 live births 
compared to 12.0 infant 
deaths per 1 ,000 live births 
among whites. 

The gap between the 
American Indian/Alaska 
Native population and the 
white population narrowed 
with regard to infant mortality 
during a recent 8-year period 
(selection of years was based 
on availability of data for 
American Indians/Alaska 
Natives). The American In- 
dian/Alaska Native-to-white in- 
fant mortality differential 
decreased from 2.07 in 1970 
to 1.29 in 1978 (from Table 
6). The black-to-white infant 
mortality differential increased 
from 1.83 in 1970 to 1.95 in 
1980, but dropped slightly to 
1.90 in 1981 (from Table 5). 
While the white infant 
mortality rate decreased 32.6 
percent in the years between 
1970 and 1978 (about 4 per- 



52 



Figure 2 

Infant mortality rates by race: United States, 1940-1980 



White 



Black 



Deaths under 1 year 
per 1,000 live births 

1940 1950 

80 



70 



1960 



1970 



1980 



60 



50 



40 



30 



20 



10 



■HnBHBHi 



■Hi 



Source: National Center for Health Statistics: Advance Report, final mortality 
statistics, 1980. Monthly Vital Statistics Report, Vol. 32, No. 4 Supp. DHHS Pub. No. 
(PHS) 83-1120. Public Health Service, Hyattsville, MD. August 1983, Figure 5, p. 8. 



cent per year), that of 
American Indians decreased 
37.0 percent (about 4.6 per- 
cent per year), and that of 
blacks decreased 29.1 per- 
cent (3.6 percent per year) 
during the same time interval. 

Although these groups are 
the largest racial groups in 
the United States, another 
group, Asians, is of growing 
importance in this country, 
and an ethnic group, 
Hispanics, needs to be men- 
tioned. Asians are typically 
considered to be Chinese, 
Japanese, Filipinos, and 
"other Asians." However, the 
large numbers of refugees 
from Vietnam and even those 
from Afghanistan make them 
a group of current public 
health concern. Infant mor- 
tality rates for Asians are con- 
siderably better than for 
others in the nonwhite race 
category (see Tables 5, 6, 



and 7). Details regarding the 
new refugee populations are 
not available. 

The Hispanic ethnic group 
is also comprised of many 
subgroups— Mexicans, 
Puerto Ricans, Cubans, and 
now the refugees from El 
Salvador, Haiti, and other 
countries of Central and 
South America. It comprised 
6.4 percent of the U.S. 
population in 1980. The in- 
fant mortality rate for 
Hispanics has traditionally 
been included in the white 
rates, and there are no na- 
tional mortality rates for this 
group at this time (4). 
However, areas with large 
Hispanic populations often 
have relatively higher white 
infant mortality rates. Some 
States are now collecting 
data on the Hispanic popula- 



tion, so natality characteristics 
are examined later in this 
section. 

The causes of infant death 
reflect most of the diseases 
and conditions which afflict 
all humans, in addition to 
many which relate to the 
birth process. Congenital 
anomalies are the leading 
cause of death in infants and 
have a higher rate for white 
than for nonwhite infants. For 
other major causes of infant 
death, the nonwhite rates are 
substantially higher than the 
white rates, although reduc- 
tions are seen in rates for all 
causes of death and for all 
race groups. Again, where 
black data are available, the 
black infant mortality rates 
are usually higher than the 
nonwhite rates (5). 

Nonwhite races, and par- 
ticularly blacks, are also at a 
basic disadvantage in con- 
nection with fetal mortality. 
Nonwhites had a fetal 
mortality rate 1 .59 times 
greater than whites in 1981 
(see Table 5). From 1970 to 
1980, fetal mortality was 
reduced 35.9" percent. For 
whites, the reduction was 
34.7 percent, and for non- 
whites 41 .2 percent. 

It is important to review in- 
fant mortality and fetal mor- 
tality not only in terms of 
racial components but also in 
terms of age at death and 
length of gestation. The in- 
terventions to help prevent 
fetal loss and early infant 
death are quite different from 
those needed to prevent 
deaths occurring to older in- 
fants. In the first case, the 
deaths are caused by con- 
genital anomalies and condi- 
tions related to prenatal and 
birth problems, including the 
immaturity of the infant at 
birth and the health status of 
the mother. They also are 



related to the schedule of 
prenatal care. Later deaths 
tend to stem also from con- 
genital anomalies, as well as 
from acute conditions (e.g., 
respiratory infections) and ac- 
cidents. Some of these may 
be related more closely to 
the availability and utilization 
of pediatric health care (2). 

The gestation period is 
divided for our purposes into 
various lengths (12). Some 
researchers use 20-27 weeks 
of gestation versus 28 or 
more weeks (7), and others 
use term (> 37 weeks of 
gestation) versus preterm 
(<37 weeks of gestation) 
(11). A fetal death is defined 
as a birth without required 
signs of life occurring after 
20 weeks or more of 
gestation. 

The period of infancy (the 
first 12 months of life) is 
divided into the neonatal 
period (the first 28 days of 
life) and the postneonatal 
period (the remaining 29-364 
days). The neonatal period is 
itself further divided into time 
frames related to risk of 
death— under 1 day (0 day), 
1-6 days (the rest of the first 
week of life), and 7-27 days. 

The majority of infant 
deaths occur during the 
neonatal period. In 1980, 8.5 
of the 12.6 infant deaths per 
1,000 live births (67.5 per- 
cent) occurred during the 
neonatal period; 4.1 of the 
12.6 infant deaths per 1,000 
(32.5 percent) occurred dur- 
ing the postneonatal period. 
In 1981, the neonatal rate, 
8.0, and the postneonatal 
rate, 3.9, maintained the 
same general distribution 
(67.2 and 32.8 percent) (see 
Tables 5, 6 and 9). 

Postneonatal mortality 
rates (not given in Table 5 
but included in Tables 6 and 



53 



7) may be calculated by 
subtracting neonatal mortality 
rates from infant mortality 
rates. The proportion of 
deaths for American In- 
dians/Alaska Natives for the 
neonatal and postneonatal 
periods do not have the 
same distribution seen in the 
rest of the population. They 
are almost evenly divided 
between the two periods. The 
mortality rate differentials of 
American Indians/Alaska 
Natives and blacks to all 
races were calculated for 
1970 and 1978. (These are 
years for which data are 
available for American In- 
dians/Alaska Natives.) 



Neonatal 

mortality 

rate 
Postneonatal 

mortality 

rate 



Some striking differences 
may be noted. First, neonatal 
mortality rates of American 
Indians/Alaska Natives in 
both 1970 and 1978 were 
lower than those of the total 
population. Second, among 
both American Indians/Alaska 
Natives and blacks, greater 
disparities with the total 
population occurred in post- 
neonatal mortality rates than 
in neonatal mortality rates. 
Third, the differentials sug- 
gest that, among both 
groups, greater improve- 
ments relative to the total 



population occurred in post- 
neonatal mortality rates than 
in neonatal mortality rates. 
The postneonatal mortality 
rates decreased 38.2 percent 
for American Indians/Alaska 
Natives, 22.4 percent for 
blacks, and only 10.0 per- 
cent for whites from 1970 to 
1978. The neonatal rates 
from 1970 to 1978 were 
reduced 39.1 percent for 
whites; for all other races the 
reduction was 34.6 percent, 
and for blacks the reduction 
was 32.0 percent. 

As with the infant mortality 
rate, the neonatal and post- 
neonatal rates for Asians are 
substantially lower than for all 



1978 



1.63 



1.77 



other races, including whites 
(5). 

The reduction of infant 
mortality rates continues to 
be a national goal in the 
United States. The specific 
goal as stated in Promoting 
Health/Preventing Disease 
follows. "By 1990, no county 
and no racial or ethnic group 
of the population (e.g., black, 
Hispanic, Indian) should have 
an infant mortality rate in ex- 
cess of 12 deaths per 1,000 
live births." (3, p. 17) 

National infant mortality 
rates for racial groups have 
previously been presented. It 
would appear that whites and 



various Asian groups have 
already reached the 1990 
goal for their total U.S. 
populations. The other races 
must have a reduction of 
32.6 percent in the next 9 
years, or 3.6 percent a year. 
Blacks must reduce infant 
mortality by 40 percent dur- 
ing the next 9 years, 4.4 per- 
cent a year. This is the na- 
tional picture; to achieve the 
goal for each city and county 
as well adds another dimen- 
sion to the challenge (6). In 
1979, of 59 major U.S. cities, 
32 had white infant mortality 
rates higher than 12 per 
1 ,000 live births. The white 
infant mortality rate in 
Baltimore City was 20.8 per 
1,000. The nonwhite infant 
mortality rate in 1979 in 52 
out of 59 major U.S. cities 
was over 12 per 1,000, and 
in 29 of these cities it was 
over 20 per 1,000. For over 
60 percent of the 3,131 
counties of the United States, 
the 5-year average rate for 
1979-1980 was greater than 
the goal of 12 infant deaths 
per 1,000 live births (6, p. 
103 and 7). 

3. Factors Associated with 
Infant Mortality and 
Morbidity 

It is natural to ask why a 
country such as the United 
States has such high infant 
mortality compared with other 
industrialized countries; why 
this Nation has not improved 
its relative position over the 
years; and why infant 
mortality rates among some 
minority groups are ap- 
preciably higher than those 
of the population as a whole. 

The many analyses of the 
relationship of characteristics 
of the mother, the infant, and 
the reproductive event to 
reproductive outcomes iden- 



tify the characteristics which 
seem to be more closely 
related to high risk of poor 
outcomes. Providers are 
alerted to take special 
precautions for women with 
these characteristics, or to 
provide special services. 
Thus, while it is not possible 
to define the precise value 
and impact of each element 
of prenatal care on each in- 
fant, it is clear that, as 
groups, mothers who seek 
care early, who have an ap- 
propriate number of visits, 
who space their infants so 
that their own bodies have 
recovered from a previous 
pregnancy, and who deliver 
in hospitals have better 
reproductive outcomes than 
others (10, 12). This section 
reviews some of these 
characteristics in terms of 
racial, ethnic, and low in- 
come groups, 
a. Low Birth weight 

Prior to 1979, low birth- 
weight referred to an infant- 
weighing 2,500 grams (5 Vz 
pounds) or less at birth, 
whether the infant was born 
"full term" or premature 
(before 37 weeks of gesta- 
tion) (3, p. 1). This criterion 
was recommended by the 
American Academy of 
Pediatrics in 1935. In 1979, 
the criterion was changed 
from 2,500 grams or less to 
less than 2,500 grams. This 
newer definition is consistent 
with the Ninth Revision of the 
International Classification of 
Diseases. The National 
Center for Health Statistics 
(NCHS) states that the 
change in definition has very 
little impact on the com- 
parative statistics. 

Definitions for very low 
birthweight infants are not so 
consistent. Some research 
studies use "under 2,000 



Mortality Differentials to All Races 

American 
Indian/Alaska 

Native Bla< 
1970 1978 1970 



.81 .82 1.51 



2.51 1.77 2.00 



54 



grams" (7, 12) and the 
NCHS in many of its reports 
now uses "under 1,500 
grams." In either case, the 
increased risk of death and 
morbidity among very low 
birthweight infants is well 
documented (8, 9). Neonatal 
mortality among low birth- 
weight infants is over 20 
times as high as among 
heavier infants. Morbidity, 
particularly that associated 
with the central nervous and 
respiratory systems, is higher 
among low birthweight infants 
than among other infants (10, 
p. 28). 

A rise in the proportion of 
low birthweight infants 
occurred in the United States 
during the 1960's, but it 
started to drop again in the 
early 1970's (see Table 7). 
Due to the smaller decrease 
in the proportion of low birth- 
weight births among blacks, 
the racial differential between 
black and white low birth- 
weight infants was slightly 
greater in 1980 than in 1970 
(2.04 in 1970, 2.19 in 1980). 

While the ratio of low birth- 
weight infants born to blacks 
is considerably greater than 
the ratio born to all races, 
some other racial/ethnic 
minorities (as well as the 
white majority) have a lower 
ratio of low weight births than 
the general population. In the 
most recent data year for 
American Indians/Alaska 
Natives, 1978, this group had 
a low birthweight incidence 
of 6.5 percent compared with 
an incidence of 7.1 percent 
for the general population in 
the same year (see Table 
11). Birthweight data have 
become available only 
recently for Hispanics, who 
had a lower ratio of low birth- 
weight in 1980, 6.1 percent, 



compared with the general 
population ratio of 6.9 per- 
cent (see Table 9). 

"In light of the large 
number of deaths and the 
severe physical and mental 
handicaps that can accom- 
pany low birthweight, in- 
creasing attention has been 
focused on some of the 
associated factors." (10, p. 1) 
An in-depth study of 1976 
birth certificates was con- 
ducted by the Division of 
Vital Statistics of the National 
Center for Health Statistics. 
Some of the findings of that 
study were: 

1) Birthweight increased 
with socioeconomic status of 
the family (as measured by 
the educational attainment of 
the mother) (10, pp. 1-2). 

2) Age of mother is also 
related to birthweight. 
Mothers at each end of the 
childbearing age spectrum 
were more likely to bear low 
birthweight infants, while 
mothers age 25-29 years 
were least likely to bear a low 
birthweight baby (10). 

3) Regardless of age, 
married mothers were less 
likely to bear a low birth- 
weight infant than were un- 
married mothers (10). 

4) Also regardless of age, 
" . . . mothers were least 
likely to bear a low birth- 
weight baby when the inter- 
val between births was 2-4 
years." (10) 

5) A far higher proportion 
of all nonwhite infants than 
white infants is of low birth- 
weight. However, the large 
proportion of low birthweight 
infants is not common to all 
nonwhite births. In 1976, the 
incidence of low birthweight 
was highest among black in- 
fants (13.0 percent) and 
lowest among Chinese infants 
(5.7 percent) (10). 



To summarize findings 
regarding birthweight based 
on birth certificate data, 
". . . the incidence of low 
birthweight in the United 
States varies widely by race 
and by mother's age, marital 
status, . . . and pregnancy 
history. The socioeconomic 
status of the family, as 
measured by the mother's 
educational attainment, ap- 
pears to be one of the most 
critical factors, however, in 
determining birthweight." (10, 
pp. 1-2) Also related are birth 
order, interval between births, 
the timing of start of care, 
and number of prenatal care 
visits (12). A study examining 
reductions in low birthweight 
between 1970 and 1980 
determined that most of the 
reduction came from the 
group of infants with at least 
37 weeks' gestation (11). 

From studies of low birth- 
weight which analyze data 
not found on birth certificates, 
other factors have been 
shown to be related to low 
birthweight incidence. For in- 
stance, it is believed that in- 
adequate maternal nutrition is 
the cause of about one-third 
of low weight births (13). In 
addition, the proportion of 
low birthweight newborns has 
been seen to be higher 
among mothers who start 
their prenatal care later in the 
pregnancy or do not receive 
any care (14). Major efforts 
are now being made to im- 
prove the nutrition status of 
women during pregnancy. 
These include nutrition and 
diet counseling as well as 
food supplement programs 
(e.g., the Women, Infant and 
Children Supplemental Food 
Progam [WIC]) for mothers 
identified as having special 
needs, and for their young 



children. A major effort has 
also been undertaken in re- 
cent years to encourage new 
mothers to breastfeed their 
newborns as a means of pro- 
viding an appropriate level of 
sustenance to the infant. This 
includes a Surgeon General's 
Workshop on Human Lacta- 
tion. National data are not 
available which directly 
assess the nutrition status of 
mothers and infants, but the 
data which are available from 
the National Health and Nutri- 
tion Examination Survey, 
1976-1980, indicate that diet 
intake of protein per 1,000 
calories for women 15-44 
years of age living at or 
below the poverty income 
level is 2 to 4 grams lower 
than for women 15-44 years 
of age living above the 
poverty level. The intake of 
vitamins A and C, calcium, 
and iron reflected the same 
patterns of lower intake for 
women age 15-44 years liv- 
ing at or below poverty (21). 
Some aspects of the impact 
of nutrition on genetic prob- 
lems are discussed later in 
this chapter. 

In studies which examine 
lifestyle variables, the smok- 
ing, drinking, and drug 
abuse habits of expectant 
mothers have been shown to 
be determinants of infant 
weight and health. Even 
moderate use of alcohol 
during pregnancy is 
associated with a significant 
decrease in birthweight (1, p. 
508, and 15, p. 81, 16, 17, 
18, 19). 

Many factors related to 
poor reproductive outcomes 
are also related to one 
another, and in combination 
seem to have a dispropor- 
tionate impact on an infant's 
health status (12, 20). 



55 



b. Mother's Age, Parity, and 

Marital Status 

"Pregnancies among 
teenagers, among women 
who are unmarried, among 
women over the age of 34, 
and among high parity (and 
gravidity) women are all 
associated with higher than 
average rates of maternal 
and/or infant morbidity and 
mortality." (3, p. 11) In each 
of these circumstances of 
pregnancy, an infant is more 
likely to be unintended and 
unwanted than in the case of 
pregnancies among married 
women in the most favorable 
childbearing years who do 
not already have any children 
or as many as desired (3, p. 
11). 

The physiological and 
psychological immaturity of 
very young mothers poses a 
health risk to the infant as 
well as to the mother (3, p. 
15). ". . . Teenage pregnan- 
cies are associated with 
markedly increased risks of 
maternal morbidity and mor- 
tality and of premature and 
term low birthweight infants 
who have reduced chances 
of surviving infancy and high 
rates of serious neurological 
impairment." (3, p. 1 1) 

With regard to the first- 
mentioned risk factor, 
mother's age, black teenage 
birth rates are higher than 
white teenage birth rates. The 
birth rate in 1980 among 
black girls aged 15 to 17 
years (73.6 per 1,000 live 
births) was almost three times 
the birth rate for white girls of 
that age group (25.2 per 
1 ,000 live births) (see Table 
13). The rate decreased for 
this age group between 1970 
and 1980 by 13.7 percent for 
whites and 27.4 percent for 



blacks. Birth rates are 
substantially higher among 
black women than white 
women in each age group, 
with the exception of the 
25-29 and the 30-34 groups, 
which are very similar. The 
differentials are greater, 
however, for the very ages 
that are at highest risk for 
childbearing. For instance, 
the largest black-to-white dif- 
ferential for birth rates in 
1980 is among 10- to 
14-year-olds (3.58), followed 
by that for 15- to 17-year-olds 
(2.26), 18- to 19-year-olds 
(1.69), 40- to 44- year-olds 
(1.49), and 45- to 49-year- 
olds (1 .50). The total 
black/white birthrate differen- 
tial in 1980 was 1.23 (22). 

Pregnant teenagers ac- 
counted for 16 percent of the 
infants born in 1980 (22, p. 
10). Early teenage childbear- 
ing is higher in the United 
States than in other countries. 
Some of that higher rate is 
accounted for by blacks, but 
even among whites aged 1 7 
and younger, fertility is higher 
in the United States than in 
27 of the 30 countries 
studied (23, p. 104). Several 
explanations for this dif- 
ference (abortion laws, finan- 
cial benefits to teenage 
mothers, family planning 
services) were considered 
and discarded. An intercoun- 
try study undertaken by 
Princeton University and the 
Alan Guttmacher Institute has 
examined intercountry and in- 
terstate differences in 
teenage fertility, abortion, and 
pregnancy rates, as well as 
the reasons for these dif- 
ferences (23a, pp. 53-63). 

Parity, the second risk 
factor under discussion in this 
section, refers to the live birth 
order of each infant born to 
one woman. Thus a "high 
parity woman" (multipara) is 



a woman who has given birth 
to a relatively large number 
of live children and whose 
health reflects the toll of bear- 
ing this large number of in- 
fants. It is distinct from other 
measures, such as birth rate 
(which characterizes the 
number of births per 1 ,000 
women in a given age group 
within a specified geographic 
area using as a base 
reference all women of 
childbearing age [15-44 
years] living within that area, 
whether or not they have a 
child) and fertility rate (which 
is the sum of birth rates for 
all years for a specified age 
group). 

The drain of childbearing 
on the mother, the adverse 
impact of high birth order on 
infants, and the difficulties for 
a family in providing for large 
numbers of children is shown 
(see Table 14) to be a 
greater problem for other 
races than for whites and to 
be greatest for Hispanics (22, 
24). 

Based on data from the 
1976 National Survey of 
Family Growth (25, p. 2), 39 
percent of black couples 
compared with 33 percent of 
white couples had three or 
more children (25, p. 9). 
Also, the percentage of black 
couples with no children is 
lower (1 1 .0 percent) than that 
of white couples (19.0 per- 
cent) (25, p. 9). 

Marital status is the last 
risk factor included in this 
section. Infant mortality is 
higher among births to un- 
married women than to mar- 
ried women. Out-of-wedlock 
births may affect infant mor- 
tality because of the stress in- 
volved, because they include 
many younger mothers, or 
because they often occur to 
mothers of lower 



socioeconomic status. Blacks 
had a rate of 82.9 births per 
1,000 unmarried women in 
1980, while the white rate 
was 17.6 (see Table 15). 
Although the out-of-wedlock 
birth rate of blacks was 4.71 
times that of whites in 1980, 
between 1970 and 1980 the 
unmarried birth rate had in- 
creased 27.5 percent among 
whites, but decreased 13.2 
percent among blacks. The 
out-of-wedlock birth rate of 
52.0 births per 1,000 unmar- 
ried Hispanic women in 1980 
was also considerably higher 
than that of whites, but it was 
lower than the rate among 
blacks (see Tables 15 and 
16). The birth rate of all un- 
married women in 1980 was 
29.4 per 1,000 unmarried 
women (see Table 15). 
c. Socioeconomic Factors 
and Medical Care 

In this section, the part 
played by socioeconomic 
level on poor reproductive 
outcomes is discussed with ■ 
respect to differing patterns 
of medical care during 
pregnancy. The 
socioeconomic level is known 
to be inversely related to the 
infant mortality level (10). 
Without exception, all of the 
risk factors already discussed 
have a direct relationship to 
socioeconomic level. Few 
studies of infant mortality 
have income data and none 
were found which examined 
the impact of socioeconomic 
measures on mortality while 
controlling for mother's age 
at pregnancy, marital status, 
parity, and low birthweight. 
Concern has been focused 
on identifying the high-risk 
patient and the characteristics 
that indicate a possibility of 
intervening. Various health 



56 



and nutrition programs have 
been developed to help ease 
the impact of poverty on the 
health of mothers and infants 
and on the availability of 
quality medical care. 

Nonetheless, the effect of 
socioeconomic level is such 
that medical care cannot 
completely offset the higher 
risk of infant mortality and 
morbidity among the disad- 
vantaged. "The medical com- 
plications and the other 
associations with an un- 
favorable outcome of 
pregnancy are so prevalent 
among low-income high-risk 
patients, that the few months 
the obstetrician sees the pa- 
tient prior to labor are insuffi- 
cient to offset the years of 
deprivation and its effects on 
the growth and development 
of the mother." (26) 

Even so, the majority of 
observers believe that the 
amount and quality of 
medical care received by the 
mother and infant contribute 
to the best possible outcome 
of the pregnancy. Since the 
mid 1960's, when Medicaid 
legislation started to provide 
payment for prenatal care, 
delivery services, and 
postpartum care, and the 
Title V Maternity and Infant 
Care Projects were models 
for providing quality care to 
disadvantaged populations, 
these types of services have 
been more available (2, pp. 
94, 26). Birth certificate data 
for the District of Columbia 
and 48 States that report 
prenatal care on their birth 
certificates are presented in 
Table 17. In 1980, 79.3 per- 
cent of white mothers, com- 
pared with 62.7 percent of 
black mothers, began care in 
the first 3 months of 
pregnancy. While the propor- 
tion of nonwhite mothers who 
received early prenatal care 



in 1980 was lower than the 
proportion of whites, a 
greater gain in percent of 
mothers with early prenatal 
care over the past 10 years 
was experienced by nonwhite 
mothers than by white 
mothers (22). The proportion 
of nonwhite mothers who 
received no prenatal care 
(2.7 percent) in 1980 was 
considerably higher than that 
of white mothers (1 .0 per- 
cent) (22). 

The median number of 
prenatal visits for births in 
1980 by trimester (27, p. 7) 
was not too dissimilar for 
blacks and whites in 1980, 
as shown below. The dif- 
ferences were less than one 
visit per trimester. 

Median 
White 

1st trimester 12.2 
2nd trimester 9.0 
3rd trimester 4.9 



The National Ambulatory 
Medical Care Survey 
(NAMCS) is another source 
demonstrating the similarities 
in prenatal care among the 
racial/ethnic groups of in- 
terest. Chapter XI 
demonstrates that physician 
office visits by blacks are 
proportional to their number 
in the population when com- 
pared to whites. NAMCS 
data show that the proportion 
of all physician office visits 
made by black women seek- 
ing prenatal care (6.3 per- 
cent) is again not too 
dissimilar to the proportion 
for white women (7.1 per- 
cent) (27, p. 36). 

Prenatal care as reported 
on birth certificates in 22 
States for the Hispanic 
population is presented in 
Table 18. In 1980, a lower 



Almost all births among 
whites (99.0 percent), non- 
whites (99.1 percent), and 
blacks (99.1 percent) 
occurred in a hospital in 
1980 (see Table 19). This 
proportion of Hispanic 
women (60.3 percent) began 
prenatal care during the first 
trimester than did white non- 
Hispanic women (81.3 per- 
cent). The proportion was 
similar to that of black non- 
Hispanic women (61.1 per- 
cent). In addition, a far higher 
proportion of Hispanic 
mothers (3.8 percent) and 
black non-Hispanic mothers 
(3.2 percent) received no 
prenatal care compared with 
white non-Hispanic women 
(0.8 percent). 

Visits 

Difference 

0.9 
0.8 
0.5 



percentage among nonwhites 
represents a major gain since 
1960, when only 85.0 per- 
cent of nonwhite births 
occurred in a hospital. Births 
attended by a physician 
dropped from 99.5 percent in 
1970 to 99.1 percent in 1975 
and 97.2 percent in 1980, 
reflecting an interest in 
natural childbirth and alter- 
native birth methods. This 
basic picture is also true of 
individual racial groups. 
4. The Problems of Un- 
wanted Fertility and 
Infertility 

These problems are often 
equated with prevention of 
unwanted pregnancies using 
various components of family 
planning (including con- 
traception) and abortions. But 
in fact, family planning has 
as its aims the appropriate 
spacing of pregnancies and 
the reduction of those 



pregnancies that unfavorably 
affect or jeopardize maternal 
and infant health. 

"Family planning is a 
preventive health measure 
which supports maternal and 
infant health and. . .includes 
measures both to prevent 
unintended fertility and to 
overcome unintended 
infertility." (3, p. 11) It is 
directed to both men and 
women, and includes educa- 
tion and service provision 
primarily in the area of con- 
traceptive use, although the 
growth in improved 
technology aimed at infertility 
is widely publicized and in- 
cludes efforts to regularize 
and stimulate ovulation, test- 
tube fertilization, and implan- 
tation in utero. 

Of the 9.3 million family 
planning visits reported in 
1980, 70.5 percent were 
made by white women, 27.4 
percent were made by black 
women, and 2.1 percent 
were made by races other 
than white or black (see 
Table 20). Relative to their 
population distribution (11.7 
percent of the total popula- 
tion), blacks are higher 
utilizers of (reporting) family 
planning clinics than whites. 
In terms of ethnic origin, 12.6 
percent of visits were made 
by Hispanic women. For the 
most part, these visits do not 
include those made by 
women to their private physi- 
cians (see Table 20). 

The estimated percentage 
of currently married white 
women using some form of 
contraception was 68.8 in 
1976 compared with 58.8 
percent of currently married 
black women (see Table 21). 
Between 1965 and 1976, the 
proportion of white women 
estimated to be using some 



Number of 
Black 

11.3 
8.2 
4.4 



57 



type of contraception 
increased by 4.7 percent 
(from 64.1 to 68.8 percent) 
while the proportion of black 
women reporting some type 
of contraception increased 
only 2.4 percent (from 56.2 
to 58.6 percent) (see Table 
21). 

Various campaigns and 
pressures have affected use 
of contraceptives: 

1 ) Adverse side effects of 
some contraceptive methods 
became known; 

2) Compaigns by religious 
and/or race groups have op- 
posed contraception; 

3) The rapid spread of 
herpes and other social 
diseases slowed indiscrimi- 
nant sexual activities among 
some groups. 

Prior to the liberalization of 
abortion laws, women of low 
socioeconomic status were 
more likely to have no abor- 
tions, or worse, to have self- 
induced abortions or abor- 
tions by nonlicensed practi- 
tioners. In contrast, women in 
higher income brackets could 
take advantage of the liberal 
practices of some private 
physicians. As would be ex- 
pected, no reliable data exist 
on abortion practices prior to 
1970. Since 1970, abortion 
clinics have witnessed a 
steady increase in the pro- 
portion of nonwhite women 
patients. 

The number of reported 
legal abortions has increased 
each year from 1973 to 1980 
for both whites and non- 
whites, with the exception of 
a 1 .1 percent decrease 
among nonwhites from 1978 
to 1979 (see Table 22) (28). 
The average annual percent- 
age increase between 1973 
and 1980 was higher among 



nonwhites (13.7 percent) than 
among whites (10.4 percent). 
It is not known if terrorist 
bombings on abortion clinics 
throughout the United States 
beginning in 1983 will have 
any impact on those who 
might seek abortions from 
this source. 

The 1976 NCHS National 
Survey of Family Growth 
(NSFG) cites infertility data 
based on personal interviews 
of 8,611 women ages 15 to 
44 (25, p. 4). In this survey, 
" . . .fecundity refers to the 
ability (at date of interview) of 
a currently married couple to 
reproduce, that is to have 
live born children; ..." (25, 
p. 45). Infertility refers to 
couples " . . .who were not 
surgically sterile and were 
continuously married, did not 
use contraception, and did 
not have a pregnancy for at 
least 12 months before the 
date of interview." (25, p. 15) 
Impaired fecundity includes 
those who are either infertile 
or surgically sterile. 

While birth rates and 
fertility rates of black women 
are higher than those of 
white women (see Chapter 
III), black couples were found 
to be much more likely to 
have impaired fecundity than 
were white couples (23 per- 
cent compared with 15 per- 
cent) (25, p. 9). Also, among 
black wives with no children 
(zero parity), 35 percent had 
impaired fecundity as com- 
pared with 21 percent of 
white wives with no children 
(25, p. 9). Since a smaller 
proportion of black wives had 
no children, however, 
" . . .the proportion of all 
couples who had no children 
and impaired fecundity was 
about 4 percent for both 
white couples and black 
couples. Thus if being 
childless and having impaired 



fecundity is one definition of 
infertility problems, these 
problems were not more 
common among black 
couples than among white 
couples in 1976. However, if 
having a fecundity impair- 
ment at parity one, two, or 
three or more is also con- 
sidered an infertility problem, 
these problems were more 
common among black than 
among white couples." (25, 
pp. 9-10) 

While the cause of higher 
impaired fecundity among 
black women in comparison 
with white women will not be 
explored at length here, 
some of the risk factors are 
listed below. These are 
known or suspected risk fac- 
tors found in the NCHS 
document "Reproductive Im- 
pairment Among Married 
Couples: United States" (25, 
p. 10). 
They are: 

1) Genetic factors, in- 
cluding sickle cell 
anemia; 

2) Alcohol and drug 
abuse; 

3) Nutritional diseases; 

4) Infectious diseases, 
such as gonorrhea; and 

5) Infections after child 
birth or after a poorly 
performed abortion. 

The higher rate of im- 
paired fecundity that has 
been observed among black 
women is an important 
finding. This is so not 
because black women bear 
fewer children than white 
women (they do not), but 
rather because the higher 
rates of impaired fecundity 
among black women imply 
higher levels of morbidity 
among black women com- 
pared with white women. 



C. Sexually Transmitted 
Diseases (STD's) 

"Sexually transmitted 
diseases (STD's) are infec- 
tious diseases grouped 
together because they 
spread by transfer during 
sexual contact. Women and 
children bear an inordinate 
share of the sexually transmit- 
ted disease burden: sterility, 
ectopic pregnancy, fetal and 
infant deaths, birth defects 
and mental retardation." (3, 
p. 25) In 1978, estimated 
costs for the most common 
STD, gonorrhea, were over 
$770 million a year, while 
total costs for all sexually 
transmitted diseases exceed 
$1 billion annually (3, p. 25). 
In 1980 there were over 1 
million reported cases of 
gonorrhea and syphilis, 
primary and secondary, in 
the United States (28, p. 
120). The true incidence of 
STD's is probably sub- 
stantially higher, since the 
Center for Disease Control 
estimates that only about half 
of all known cases are 
reported (29, p. 75). 

"Increased sexual con- 
tacts . . . have led to an in- 
creased incidence of sexually 
transmitted, or venereal 
diseases." (29, p. 75) Other 
factors may have contributed 
to the increase in STD in- 
cidence. One major factor is 
the more widespread use of 
oral contraceptives and in- 
trauterine devices (lUD's), 
which lack the protection 
from disease " . . .afforded 
by the condom and vaginal 
contraceptives." (30) One of 
the goals set forth in Pro- 
moting Health/Preventing 
Disease is to reduce STD in- 
cidence by increasing utiliza- 
tion of these preventive 
measures. Specifically, the 
national goal is to increase 



58 



condom use among sexually 
active men and women from 
the current estimated 10 per- 
cent to 25 percent by 1 990 
(3, p. 27). 

While there are at least 16 
sexually transmitted diseases 
(31, p. 98), only 4 will be 
discussed in this chapter. 
Selection was based on an 
assessment of the public 
health impact of these 
diseases as measured by the 
extent to which they are ad- 
dressed in the current 
literature, and/or the 
availability of published in- 
cidence rates by race. 
1. Syphilis 

"Syphilis may be a fatal or 
seriously disabling disease 
causing irreversible damage 
to the cardiovascular, central 
nervous, or musculoskeletal 
systems. One of every 13 un- 
treated patients with syphilis 
will develop cardiovascular 
disease, one of 25 will 
become crippled or in- 
capacitated, and one of 44 
will develop irreversible 
damage to the central ner- 
vous system. One patient in 
every 200 with untreated 
syphilis will become blind." 
(32, p. 482) 

The greatest increases in 
syphilis occurred during the 
1960's (33, p. 78). The 
observed decreases in late 
and latent syphilis between 
1967 and 1979 (see Figure 
3) were attributed to effective 
serological screening leading 
to identification and treatment 
of early cases (33, p. 78). 

Syphilis ranks third in 
prevalence (after chicken pox 
and gonorrhea) among 
reported communicable 
diseases in the United States. 
In 1979, there were 67,049 
reported cases of syphilis (all 
stages), 32.0 per 100,000 
population. This represents a 



Figure 3 

Annual reported cases in the United States (excluding California and New 
York) per 100,000 population of primary and secondary syphilis by race 
(white and all other), sex, and reporting source for 1967-1979. 



Male 

Syphilis 
Cases 

1967 

100.0 



Female Whites— Private 



Male 



Female Whites— Public 



1969 



Calendar Years 

1971 1973 1975 



Syphilis 
Cases 



1977 1979 



1967 1969 



Calendar Years 

1971 1973 1975 



1977 1979 



10.0 



1.0 



0.1 



100.0 



10.0 



1.0 



0.1 



Male 



Female All Other Races— Private 
Calendar Years 



Male 



Female All Other Races— Public 
Calendar Years 



gj» C„.„ to Yea, s ST 

1967 1969 1971 1973 1975 1977 1979 1967 1969 1971 1973 1975 1977 1979 

100.0 100.0 



10.0 



1.0 



0.1 



10.0 



1.0 



0.1 



Source: "Syphilis in the United States: 1967-1979," Sexually Transmitted Diseases, 
Fichtner, R.R., Aral, S.O., Blount, J.H., Zaidi, A.A., Reynolds, G.H., Danon, W.M. 
1983:10: 72-76. Table 1, p. 73. 



59 



Figure 4 

Composition by diagnosis of total reported morbidity due to syphilis in the 
United States for 1969 and 1979. 



1969: 

Late& 
Late Latent 



Primary & 
Secondary 



Early Latent 
(< 1 year) 



Congenital 



1979: 

Late& 
Late Latent 



Primary & 
Secondary 



Early Latent 
( < 1 year) 



Congenital 



Percent of Syphilis Cases 



10 



20 | 



30 



40 



50 



60 



Source: "Gonorrhea in the United States: 1967-1969," Sexually Transmitted Diseases, 
Zaidi, A.A., Aral, S.O., Reynolds, G.H., Blount, J. H., Jones, O.G., Fichtner, R.R., 1983:10 
72-76. Table 1, p. 73. 



33.5 percent decrease from 
the 1969 rate of 46.2 (34, p. 
16). The primary and secon- 
dary syphilis case rate was 
9.6 per 100,000 population in 
1969, increased to 12.1 in 
1974, then dropped to 11.4 
in 1979. Late and latent 
syphilis rates show the 
greatest reduction during this 
10-year period, from 27.3 in 
1969 to 9.7 in 1979. 

Syphilis case rates per 
100,000 population are 
higher among nonwhites than 
whites, as shown in Figure 3. 
Syphilis case rates by age, 
race, and setting are found in 
Table 23, which excludes 
California and New York 
(because these States do not 
consistently report cases by 
race and sex). Syphilis rates 
have generally decreased 
between 1967 and 1979, but 
rates among all age groups 
of white men in public clinics 
and older white men in 
private clinics have 
increased, as have those of 
young white women in public 
clinics. In fact, three striking 
changes occurred between 
1967 and 1979. First, the in- 
crease in attack rate among 
white men as reported from 
public clinics contributed to 
the increase in the attack rate 
differential of white male to 
white female cases, from 
1.5:1 in 1967 to 3:1 in 1979 
(33). Second, the 
"... percentage of white 
men with early syphilis who 
attended public clinics and 
reported at least one male 
sex partner increased from 
38 percent in 1969 to 70 per- 
cent in 1979." These findings 
suggest that an essential 
change occurred in the 
epidemiology of early syphilis 
in the United States as 



reflected in the increasing 
levels of transmission of 
syphilis within the white 
males of the population (33). 
Third, the increase in syphilis 
attack rates among white 
males between 1967 and 
1979 reduced the racial dif- 
ferential among males. The 
nonwhite-to-white differential 
for attack rates was reduced 
for both sexes, but this was 
influenced more by rises in 
the white rates than by 
reductions in the nonwhite 
rates. 

A higher incidence of 
syphilis is also found among 
American Indians/Alaska 
Natives than the population 
as a whole (see Table 24). 
This population had a syphilis 
rate almost twice that of the 
total population in 1967 (99.9 
per 100,000 population com- 
pared with 52.5), and 
although both groups 
showed greatly reduced 
rates, this differential 
increased to 2.25 times that 
of the total population by 
1981 (72.0 compared with 
32.0). 

Even though rates are be- 
ing reduced for all races and 
most sex/age group com- 
ponents, the nonwhite 
(primarily black and 
American Indian/Alaska 
Native) rates remain substan- 
tially higher in all 
components. 
2. Gonorrhea 

Since 1965, gonorrhea 
has been the most frequently 
reported communicable 
disease in the United States 
(35). Approximately 1 million 
cases have been reported 
each year since 1975 (34, p. 
5). Authoritative sources 
report that "the number of in- 
fections occurring exceeds 
reported cases, and an 
estimated 1.6 to 2.0 million 
cases occur annually." (34, 



p. 5) In 1979, 59 percent of 
reported gonorrhea cases oc- 
curred among men (34, p. 
5). However, recent increases 
have been greater among 
women, and the complica- 
tions of gonorrhea are more 
keenly felt by women. 

"Pelvic inflammatory 
disease is the most serious 
complication of gonorrhea 
and chalmydial infections. 
More than 850,000 cases are 
diagnosed and treated each 
year; the major proportion of 
these are associated with 
past or present sexually 
transmitted disease. In 1978, 
it was estimated that 150,000 
new cases of pelvic inflam- 



matory disease were caused 
by gonorrhea." (3, p. 25) 
"Complications of gonorrhea 
in women account for 78,000 
to 97,200 hospital admis- 
sions, totaling 518,200 to 
645,600 hospital days an- 
nually." (34, p. 6) More infor- 
mation about pelvic inflam- 
matory disease is found in 
Chapter IV, Section C. 

Gonorrhea attack rates 
were consistently higher 
among nonwhites of both 
sexes than among whites 
from 1967 to 1979 (see 
Figure 5). For most 
race/sex/age groups, the 



60 



Figure 5 

Reported cases of gonorrhea by race and sex. United States (excluding 
California and New York), 1967-1979. 



Female 

White 
Calendar Years 



Male 

Thousands 
of Cases 

1967 1970 1973 1976 1979 

1,000 
900 
800 
700 
600 
500 
400 
300 
200 
100 

90 

80 

70 

60 

50 

40 

30 

20 

10 
0 



Male 
Thousands 



Female 

All Other Races 
Calendar Years 



of Cases 

1967 1970 1973 1976 1979 

1,000 
900 
800 
700 
600 
500 
400 
300 
200 
100 

90 

80 

70 

60 

50 

40 

30 

20 

10 
0 



Source: "Gonorrhea in the United States: 1967-1979," Sexually Transmitted Diseases, 
Zaidi, A.A., Aral, S.O., Reynolds, G.H., Blount, J.H., Jones, O.G. Fichtner, R.R., 1983:10: 
72-76. Table 1, p. 73. 



rates peaked in 1975, 
followed by a small drop and 
plateau. The 1979 rates, 
even so, are higher than the 
1967 rates in almost all 
race/sex/age groups. For 
nonwhite females under 25, 
the increase continued 
through 1979. However, the 
generally sharper increases 
among whites since 1967, 
coupled with some plateau- 
ing of nonwhite attack rates 
since 1975, has produced 
racial differentials that are 
lower in 1979 than they were 
in 1967. 

From 1969 to 1979, the 
nonwhite gonorrhea rate 
among males dropped 11.4 
percent and the white gonor- 
rhea rate increased 55.8 per- 
cent, reducing the racial dif- 
ferential from 21 to 12. The 



racial differential among 
females also decreased from 
1969 to 1979 from 14.7 to 
9.3 because the age-adjusted 
gonorrhea rate among non- 
white women increased 
105.0 percent while the rate 
among white women in- 
creased 202.1 percent. 

The gonorrhea incidence 
among American In- 
dians/Alaska Natives 
increased 142 percent bet- 
ween 1965 and 1975 (see 
Table 24). While this group 
had 5 times the gonorrhea 
case rate of the total popula- 
tion in 1971 and 3.7 times 
the U.S. rate in 1975, the dif- 
ferential dropped to 1 .65 of 
the U.S. rate in 1981 
because of greater white in- 



Total Reported Cases 
Calendar Years 

Thousands 
of Cases 

1967 1970 1973 1976 1979 

1,000 
900 
800 
700 
600 
500 
400 
300 
200 
100 

90 

80 

70 

60 

50 

40 

30 

20 

10 
0 



creases. The rate of gonor- 
rhea incidence for American 
Indians/Alaska Natives was 
reduced in the years be- 
tween 1975 and ,1981 to 
about the 1965 level of in- 
cidence (718.4 for 1981). 
From 1965 to 1981, the U.S. 
rate went from 169.6 to a 
high in 1976 of 470.5, and 
down to a rate of 435.2 in 
1981. 

In these circumstances, 
the improved racial differen- 
tials are not seen as a 
measure of positive change. 
3. Herpes II 

"Genital infection with 
herpes simplex virus is a 
disease of major health im- 
portance. Although data on 
incidence and prevalence are 
generally unavailable, records 
from sexually transmitted 



disease clinics in the United 
States and the United 
Kingdom indicate an increase 
in the number of cases and 
rate of diagnosis of herpes 
during the past 10 years." 
(36, p. 19) Since herpes II is 
not included in the U.S. na- 
tional reporting system for 
communicable diseases, 
estimates of the prevalence 
and incidence of this disease 
vary widely. The prevalence 
is estimated to be 8 to 12 
percent in the sexually active 
population (29, p. 75), 
however, and is believed to 
be substantially higher in 
various subgroups of the 
population. 

"There is no effective pro- 
phylaxis or treatment, and 
relapsing episodes over long 
periods of time make genital 
herpes a disease of major im- 
portance to public health." 
(36, p. 15) 

"In 1978, the American 
Social Health Association 
established a program 
entitled HELP to facilitate 
dissemination of information 
to patients suffering from the 
disease." (36, p. 15) While 
no large-scale and/or ongo- 
ing study of this disease is 
available to make a 
prevalence comparison be- 
tween the racial minorities 
and the remainder of the 
population, higher rates have 
been observed both at one 
point in time and over time 
among lower socioeconomic 
groups (37) and among 
predominantly white affluent 
groups (36). 
4. Acquired 

Immunodeficiency 

Syndrome (AIDS) 

Acquired immuno- 
deficiency syndrome (AIDS) 
is a new illness in the United 
States with a rapidly increas- 



61 



Figure 6 

Acquired immunodeficiency syndrome (AIDS) cases, by quarter of 
diagnosis— United States, first quarter 1980 through December 19, 1983* 



Cases 

1980 

600 



500 



By Quarter 

1981 1982 



1983 



400 



300 



200 



100 




• Excludes 15 cases diagnosed before 1980 and 7 cases which date of diagnosis was not reported. 

Source: Center for Disease Control. Morbidity and Mortality Weekly Report Update: 
Acquired Immunodeficiency Syndrome (AIDS). United States, Vol. 32, No. 52. 
January 6, 1984. Figure 3, p. 68. 



ing incidence (see Figure 6). 
It was first recognized among 
homosexual men in California 
and New York City but has 
spread to other population 
groups and other parts of the 
country (38). It is a serious 
health problem in the United 
States today (38, p. 341) 
primarily because of its high 
mortality rate, highly infec- 
tious nature, and unknown 
cause and cure. "As long as 
the cause remains unknown, 
the ability to understand the 
natural history of AIDS and to 
undertake preventive 
measures is somewhat com- 
promised." (39) Also, as long 
as the cause remains 
unknown, categorization of 
the disease as an STD may 
be in error. It is discussed in 
this section even though its 
highest incidence is among 
homosexual men. As more is 
learned about this disease, 
however, it may be catego- 
rized as a highly infectious 
disease with other modes of 
transmission, and might 
better qualify for inclusion 
among all acute diseases. 

"As of December 19, 
1983, physicians and health 
departments in the United 
States have reported a total 
of 3,000 patients who meet 
the surveillance definition for 
acquired immunodeficiency 
syndrome (AIDS). Of the 
3,000 patients, 90.0 percent 
have been between 20 and 
49 years old. Fifty-nine per- 
cent of cases have occurred 
among whites, 26 percent 
among blacks, and 14 per- 
cent among persons of 
Hispanic origin. Women ac- 
counted for 7 percent of the 
cases. A total of 1 ,283 (43 
percent) of reported patients 



are known to have died." 
(40, p. 688) This mortality 
rate, although quite high, 
may be an underestimate 
because some recently 
diagnosed cases have not 
been followed long enough 
to assess the outcome (38). 

"Groups at highest risk of 
acquiring AIDS continue to 
be homosexual and bisexual 
men (71 percent of cases), 
and intravenous drug 
abusers (17 percent); 12 per- 
cent of patients have other or 
unknown risk factors. These 
include persons born in Haiti 
and now living in the United 
States (5 percent of total 
cases), patients with 
hemophilia (1 percent), and 
heterosexual contacts of per- 
sons at increased risk for ac- 
quiring AIDS (1 percent)." 
(40, p. 689) 

As this book is being writ- 
ten, announcements in the 



media indicate that the prob- 
able AIDS-causing virus has 
been isolated, and there 
have been predictions that a 
serum that would produce 
both a cure and a prophy- 
laxis against AIDS is prob- 
ably 2 to 5 years away. 

D. Mental Retardation 

The mentally retarded person 
is one with "significantly 
subaverage general intellec- 
tual functioning existing 
concurrently with deficits in 
adaptive behavior and 
manifested during the 
developmental period." (41) 
Mental retardation is a state 
of impairment and is not a 
disease, a syndrome, or a 
symptom. It can include both 
children and adults who, by 
virtue of their impairments in 
intellectual functioning and 
behavior, are unable to 



measure up to expectations 
and demands. The state of 
impairment termed "mental 
retardation" covers over 200 
conditions and is associated 
with and coexists with many 
causes, including 
psychological and polygenic 
influences as well as 
biological deficits. Persons 
considered to be mentally 
retarded include those with a 
broad spectrum of human 
performance ranging from 
total dependency to near 
normality. 

It is important to recognize 
and provide for the special 
needs of those affected in 
terms of services for the in- 
dividual, the family, and the 
community. At the same time, 
prevention of mental retarda- 
tion is possible, and it has 
been demonstrated that pro- 
grams such as those outlined 
below can lessen the risks of 
mental retardation for some 
and can simplify and improve 
the effectiveness of health 
service delivery. Even though 
there are no reliable national 
rates available, it is estimated 
that more than 6 million peo- 
ple, 3 percent of the total 
population, are mentally 
retarded. More than 100,000 
babies born each year are 
likely to be retarded (42). 

Genetic conditions leading 
to mental retardation are 
covered briefly in the follow- 
ing section. Mental retarda- 
tion in the low income seg- 
ment of the population prob- 
ably reflects the impact of 
socioeconomic conditions 
(e.g., the impact of low in- 
come on diet and health 
care). Strong relationships 
have been found between an 
infant's metabolism and diet 
and mental and nervous 
disorders (43). Premature 
and low birthweight infants, 
which are more common 



62 



among the race and age 
groups identified earlier in 
this chapter, are more 
vulnerable to those 
neurological and physical 
disorders that can cause 
mental retardation. 

E. Selected Genetic 
Diseases 

The estimates of the 
magnitude of genetically 
transmitted or influenced 
disorders and malformations 
vary "of necessity because of 
the dynamic process they at- 
tempt to describe." The 
World Health Organization's 
Expert Committee on Human 
Genetics estimated that 4 
percent of the world's 
population suffers from some 
serious genetic disorder, and 
other U.S. studies "reported 
that 6 percent of pediatric 
admissions were from genetic 
disorders and an additional 
15 percent have a major 
genetic component." (44, p. 
289) This is about 9 percent 
of all newborns. 

In some categories of 
genetic disease the incidence 
is very small, and in others 
quite large. The usefulness of 
programs to identify and deal 
with genetic problems is 
usually assessed in terms of 
the cost of the test and solu- 
tions versus the cost of care 
for the affected individuals. 
The recent advances in the 
tests for parental genetic 
problems and the ability to 
identify and deal with prob- 
lems in the fetus in utero, 
early and throughout a 
pregnancy, or in a newborn 
early in its life, are important 
means to reduce some of the 
problems heretofore caused 
by these defects. We do not 
question whether a parent 
carrying genes for a here- 
ditary defect should have 



children, or would want to. 
We also do not address 
whether a fetus with major 
defects or impairments 
should be aborted. These are 
choices of the individuals in- 
volved; the significant point is 
that for some genetic prob- 
lems, informed decisions are 
now possible. 

Very early screening to 
identify some problems, e.g., 
inborn errors of metabolism, 
soon after an infant is born 
permits preventive or 
ameliorative actions. Among 
the screening efforts which 
have been successful and 
cost effective are those to 
detect phenylketonuria (PKU). 
If PKU is detected within the 
first month of life and treated 
with a special diet, serious 
mental retardation can be 
prevented. Prior to screening 
and treatment, PKU ac- 
counted for about 1 percent 
of State hospital residents. 
Galactosemia can result in 
death or in both mental and 
physical damage unless the 
infant is diagnosed and is 
placed on an inexpensive 
galactose-free infant formula, 
which is lifesaving and allows 
for normal development in 
most cases. Congenital 
hypothyroidism usually leads 
to severe mental and somatic 
retardation if undetected and 
untreated with an inexpensive 
and easily managed pro- 
gram. This problem, prior to 
screenings, accounted for 1 
to 2 percent of State hospital 
residents. Screening and 
preventive actions for the Rh 
factor have long been 
known. For some other con- 
ditions, drugs or other treat- 
ment can be used to avoid 
most untoward effects. 

It is estimated that each of 
us carries, on average, 4.5 
harmful recessive genes. 
Massive screening to identify 



these, even though 
theoretically possible with 
current scientific advances in 
the study of genetics, is seen 
as having undesirable 
Orwellian overtones (43). 
Examples of diseases for 
which carrier-detection 
screening offers useful 
decision-making information 
for parents include Tay-Sachs 
disease, Duchenne's 
muscular dystrophy, Lesch- 
Nyban syndrome, and 
hemophilia. While it is possi- 
ble to determine the carrier 
status of persons with sickle 
cell trait, and while major 
screening efforts to identify 
carriers continue, this special 
problem of blacks can range 
from a painful, totally disabl- 
ing condition to a mild form 
with long periods that are 
pain free and allow normal 
functioning. It is thus more 
difficult to use a positive 
screening result as a good 
basis for decision making 
about whether a carrier of 
the sickle cell trait wishes to 
have children. 

Whether mild or severe, 
sickle cell anemia interferes 
with the health of its victims 
throughout their lives, often 
necessitating hospitalization 
for some episodes, and con- 
siderably shortening life 
spans (44). The gene respon- 
sible for sickle cell anemia 
leads to the formation of an 
abnormal form of hemoglobin 
(1, p. 167). The lifelong com- 
plications suffered by patients 
with sickle cell anemia are 
due in part to the markedly 
short life span of their red 
blood cells (45, p. 94). While 
there is no known cure nor a 
completely safe and effective 
treatment of sickle cell 
anemia, current therapy in- 
cludes massive blood transfu- 



sions. "Improved blood 
banking techniques, better 
understanding of the underly- 
ing pathophysiology of the 
microcirculation, and prompt 
intervention in states of 
severe anemia, infection, and 
acidosis have led to im- 
proved survival." (45, p. 94) 

Sickle cell anemia affects 
an estimated 50,000 people 
in the United States, and 
over 12 million Americans are 
carriers of the sickle cell trait 
(46). Sickle cell anemia is 
especially prevalent among 
blacks in America (as well as 
Africa), but occurs also 
among whites (1, p. 167). 
One estimate of the in- 
cidence of the sickle cell trait 
(from a 1980 publication) is 9 
percent among blacks in 
America (1, p. 167). Another 
recent estimate of sickle cell 
anemia (rather than the trait) 
is 1:625 (0.0189 percent) 
among black births (45, p. 
94). The most recent mortality 
data that could be located 
was for 1967, when 340 
blacks and 6 whites died of 
this disease (44). In 1978, the 
death rate of blacks from all 
forms of anemia was 2.5 per 
100,000 population (5). 

Other inherited disorders 
linked to certain racial/ethnic 
groups include cystic fibrosis, 
which primarily affects whites; 
Tay-Sachs, which occurs 
almost exclusively among 
Jews of Eastern European 
descent; and thalassemia, 
with a relatively high in- 
cidence among people of 
Mediterranean and Pacific 
Island origin (46). 
Phenylketonuria (PKU), 
which, if undetected and 
treated, usually causes 



63 



mental retardation, is most 
prevalent among people of 
European origin (47). Carriers 
of sickle cell anemia, Tay- 
Sachs, and thalassemia, as 
stated above, can be 
detected and informed about 
the risks of their children hav- 
ing the disease. Children of 
parents who have the sickle 
cell trait and who are carriers 
of Tay-Sachs and thalassemia 
traits have a 25 percent 
probability of inheriting the 
disorder and a 50 percent 
probability of themselves 
being carriers. Tay-Sachs 
disease also can now be 
detected prenatally. PKU can 
be detected when an infant is 
only a few days old, and now 
almost all infants born in the 
United States are being 
screened for this disease. 
Other inborn errors of 
metabolism can also be 
detected early, and a 
growing number of States are 
also screening for these so 
that corrective or ameliorative 
treatments can be 
undertaken. 



Table 1 

Maternal mortality rates by race. 



Year 


l otar 


wmte 


utner 


Black' 3 


Other Races/White 
Differential 


1981 


8.5 


6.3 


17.3 


20 4 


2.75 


1980 


9.2 


6.7 


19.8 


21.5 


2.96 


1970 


21.5 


14.4 


55.9 


59.8 


3.88 


1960 


37.1 


26.0 


97.9 


103.6 


3.77 


1950 


83.3 


61.1 


221.6 


223.0 


3.63 


1940 


376.0 


319.8 


773.5 


781.7 


2.42 


1 930 


673.2 


608.9 


1 1 73 9 




1.93 



a Rates per 100,000 live births. 

Source Compiled from 1) Vital Statistics of the United States, 1975. Vol. II, Mortality, Pt. A, and Vital Statistics Rates in U.S. 1940-1960; 
Final Mortality Statistics, 1977, DHEW No (PHS) 79-1120; Vol. 28, No. 1 Suppl., May 11, 1979. In Pratt, M.W. "The Demography 
of Maternal and Child Health" Maternal and Child Health Practices. Problems, Resources and Methods of Delivery. Wallace, H M., 
Gold.E M., Oglesby. A C (eds ) John Wiley and Sons, New York, 1982 2) National Center for Health Statistics: Advance report, 
Final Mortality Statistics, 1980 Monthly Vital Statistics Report, Vol 32, No. 4 Supp. DHHS Pub. No (PHS) 83-1120. Hyattsville, 
MD, August 1983 and NCHS Advance Report of Final Mortality Statistics, 1981 Vol. 33, No. 3 Supplement DHHS Pub No. (PHS) 
84-1 120. 



Table 2 

Maternal deaths and rates for Indians and Alaska Natives and All Races. 

Number Rate 1 Per 100,000 Live Births Ratio of Indian to: 



Indians and Indians and U.S. U.S. 



Calendar 


Alaska 


U.S. 


Alaska 


U.S. 


Other than 


U.S. 


Other than 


Year 


Natives 


All Races 


f J itlVI " 


All Races 


White 


All Races 


White 


1979 


4 


NA 












1978 


4 


321 


11.1 


9.6 


23.0 


1.2 


0.5 


1977 


2 


373 


8.3 


11.2 


26.0 


0.7 


0.3 


1976 


1 


390 


8.7 


12.3 


26.5 


0.7 


0.3 


1975 


4 


340 


11.8 


12.8 


29.0 


0.9 


0.4 


1974 


4 


462 


16.3 


14.6 


35.1 


1.1 


0.5 


1973 


4 


477 


23.7 


15.2 


34.6 


1.6 


0.7 


1972 


9 


612 


30.8 


18.8 


38.5 


1.6 


0.8 


1971 


9 


668 


35.0 


18.8 


45.3 


1.9 


0.8 


1970 


7 


803 


32.3 


21.5 


55.9 


1.5 


0.6 


1969 


6 


801 


32.8 


22.2 


55.7 


1.5 


0.6 


1968 


') 


859 


37.0 


24.5 


63.6 


1.5 


0.6 


1967 


7 


987 


49.1 


28.0 


69.5 


1.8 


0.7 


1966 


16 


1,049 


54.6 


29.1 


72.4 


1.9 


0.8 


1965 


12 


1,189 


63.4 


31.6 


83.7 


2.0 


0.8 


1964 


14 


1,343 


74.2 


33.3 


89.9 


2.2 


0.8 


1963 


24 


1,466 


83.7 


35.8 


96.9 


2.3 


0.8 


1962 


18 


1,465 


89.7 


35.2 


95.9 


2.5 


0.9 


1961 


17 


1,573 


66.5 


36.9 


101.3 


1.8 


0.7 


1960 


8 


1,579 


67.9 


37.1 


97.9 


1.8 


0.7 


1959 


18 


1,588 


68.8 


37.4 


102.1 


1.8 


0.7 


1958 


16 


1,581 


82.6 


37.6 


101.8 


2.2 


0.8 


NA Not Available. 



'Indian and Alaska Native rates are 3-year averages centered in the year specified. U.S. rates are for the year specified. 
Source: FY 1984 Budgeted Appropriation Indian Health Service "Chart Series" Tables. Vital Events Branch, Office of Program 
Statistics, Division of Resource Coordination. Indian Health Service, Rockville, MD, April, 1982. 



64 



Table 3 

Maternal deaths and maternal mortality rates for selected causes by race: United States, 1980. 

[Maternal deaths are those assigned to complications of pregnancy, childbirth, and the puerperium, category numbers 630-676 of the Ninth Revision International Classification 
of Diseases. 1975 Rates per 100,000 live births in specified group] 

Cause of death (Ninth Revision International All Al! otner All All other 

Classification of Diseases, 1975) races White Total Black races White Total Black 

Number Rate 



Complications of pregnancy, childbirth 



and the puerperium 




630- 


-676 


334 


193 


141 


127 


9.2 


6.7 


19.8 


21.5 


Pregnancy with abortive outcome 




630- 


-638 


62 


27 


35 


3 1 


1 .7 


0.9 


4.9 


5.3 


Ectopic pregnancy 






633 


46 


22 


24 


20 


1 .3 


0.8 


3.4 


3.4 


Spontaneous abortion 






Oo4 


Q 
O 


1 




2 


U. \ 


U.U 


U.o 


U.o 


Legally induced abortion 






635 


5 


1 


4 


4 


0.1 


0.0 


0.6 


0.7 


Illegally induced abortion 






636 


1 




1 


1 


0.0 




0.1 


0.2 


Other pregnancy with abortive 
























outcome 


630- 


-632, 637- 


-638 


7 


3 


4 


4 


0.2 


0.1 


0.6 


0.7 


Direct obstetric causes 


640- 


-646, 651- 


-676 


261 


161 


100 


90 


7.2 


5.6 


14.0 


15.3 


Hemorrhage of pregnancy and childbirth 




640-641 , 


666 


44 


27 


17 


12 


1.2 


0.9 


2.4 


2.0 


Toxemia of pregnancy 


642, 4-642.9, 


643 


60 


36 


24 


23 


1.7 


1.2 


3.4 


3.9 


Obstructed labor 






660 


















Complications of the puerperium 




670- 


-676 


93 


62 


31 


30 


2.6 


2.1 


4.3 


5.1 


Other direct obstetric 
























causes 642.0-642.3, 644-646, 651-659, 


661- 


-665, 667- 


-669 


64 


36 


28 


25 


1.8 


1.2 


3.9 


4.2 


Indirect obstetric causes 




647- 


-648 


11 


5 


6 


6 


0.3 


0.2 


0.8 


1.0 


Delivery in a completely normal case 






650 



















Source: National Center for Health Statistics: Advance report, final mortality statistics, 1980. Monthly Vital Statistics Report, Vol. 
32, No 4 Supp. DHHS Pub No. (PHS) 83-1120 Public Health Service, Hyattsville, MD, August 1983 Table 11, p. 35 



65 



Table 4 

Infant mortality rates for earlier years (1974, 1975, or 1976) and later years (1979, 1980, or 1981) for 
selected countries, showing percent change between the two years cited and annual average percent 
change in rate. 



Rank 


Country (Years) 


Rate 


Percent Change 


Earlier 


Later 


Earlier Later 


Earlier 


Later 


Total 


Annual Average 


1 


1 


Sweden (1976) (1980) 


8.3 


6.9 


- 16.87 


—4.22 


C 


2 


Japan (1976) (1980) 


9.3 


7.5 


- 1 9.35 


- 4.84 


Q 


4 


Denmark (1976) (1980) 


1 0.3 


8.4 


- 1 8.45 


— 4 61 


4 


5 


Netherlands (1975) (1981) 


1 0.6 


8.2 


- 22.64 


- 3.77 


5 


7 


Switzerland (1976) (1980) 


10.7 


9.1 


- 14.95 


-3.74 


6 


3 


Finland (1974) (1980) 


1 1 .0 


7.6 


-30.91 


-5.15 


7 


6 


Norway (1975) (1980) 


11.1 


8.1 


-27.03 


- 5.41 


8 


1 8 


England and Wales (1976) (1979) 


14.2 


12.8 


-9.86 


-3.29 


q 


q 


Australia (1975) (1980) 


14.3 


1 0.7 


- 25.1 7 


- 5.03 


1 n 


ft 


France (1974) (1980) 


14.7 


1 0.1 


- 31 .29 


- 5.22 


1 1 


10 


Canada (1975) (1979) 


15.0 


10.9 


-27.33 


-6.83 


12 


16 


UNITED STATES (1976) (1980) 


15.2 


12.6 


-17.11 


-4.28 


13 


16 


Germany (East) (1975) (1980) 


15.9 


12.6 


-20.75 


-4.15 


14 


1 1 


New Zealand (1975) (1981) 


16.0 


11.7 


-26.88 


-4.48 


15 


13 


Belgium (1975) (1980) 


16.2 


12.2 


-24.69 


-4.94 


16 


12 


Ireland (1974) (1980) 


17.8 


11.2 


-37.09 


-6.18 


17 


14 


Germany (West) (1975) (1981) 


19.7 


12.3 


-37.56 


-6.26 


18 


16 


Austria (1975) (1981) 


20.5 


12.6 


-38.54 


-6.42 


19 


20 


Czechoslovakia (1975) (1981) 


20.9 


16.8 


-19.62 


-3.27 


20 


19 


Israel (1975) (1980) 


22.9 


15.3 


-33.19 


-6.64 



Source. World Health Statistics Annual, WHO, Geneva. 1978 Vol. 1. and 1982 Vol. 1. In "The Demography of Maternal and Child 
Health" In Maternal and Child Health Practices Problems Resources and Methods of Delivery. Wallace, H.M., Gold. E.M., Oglesby, 
AC . (eds.) John Wiley and Sons, 1982 Table 4 16, p 92 



86 



Table 5 

Infant, maternal, and neonatal mortality rates, and fetal mortality ratios, by race: 1940 to 1981. 

[Deaths per 1,000 live births, except as noted. Prior to 1980, excludes Alaska and Hawaii. Beginning 1970, excludes deaths of nonresidents of U.S.] 



Item 


1940 


1950 


1960 


1965 


1970 


1975 


1976 


1977 


1978 


1979 


1980 


1981 


Infant deaths 2 


47.0 


20.2 


26.0 


24.7 


20.0 


16.1 


15.2 


14.1 


13.8 


13.1 


12.6 


11.9 


White 


43.2 


26.8 


22.9 


21.5 


17.8 


14.2 


13.3 


12.3 


12.0 


1 1.4 


11.0 


10.5 


Black and other 


73.8 


44.5 


43.2 


40.3 


30.9 


24.2 


23.5 


21.7 


21.1 


19.8 


19.1 


17.8 


Black 


72.9 


43.9 


44.3 


41.7 


32.6 


26.2 


25.5 


23.6 


23.1 


21.8 


21.4 


20.0 


Maternal deaths 3 


378.0 


83.3 


37.1 


31.8 


21.5 


12.8 


12.3 


11.2 


9.6 


9.6 


9.2 


8.5 


White 


319.8 


61.1 


26.0 


21.0 


14.4 


9.1 


9.0 


7.7 


6.4 


8.6 


6.7 


6.3 


Black and other 


773.5 


221.6 


97.9 


83.7 


55.9 


29.0 


26.5 


26.0 


23.0 


22.7 


19.8 


17.3 


Black 


781.7 


223.0 


103.6 


86.3 


59.8 


31.3 


29.5 


29.2 


25.0 


25.1 


21.5 


20.4 


Fetal deaths 4 


(NA) 


19.2 


16.1 


16.2 


14.2 


10.7 


10.5 


9.9 


9.7 


9.4 


9.1 


8.9 


White 


(NA) 


17.1 


14.1 


13.9 


12.4 


9.5 


9.3 


8.7 


8.5 


8.4 


8.1 


8.0 


Black and other 


(NA) 


32.5 


26.8 


27.2 


22.6 


16.0 


15.2 


14.6 


14.7 


13.0 


13.3 


12.7 


Neonatal deaths 5 


28.8 


20.5 


18.7 


17.7 


15.1 


11.6 


10.9 


9.9 


9.5 


8.9 


8.5 


8.0 


White 


27.2 


19.4 


17.2 


16.1 


13.8 


10.4 


9.7 


8.7 


8.4 


7.9 


7.5 


7.1 


Black and other 


39.7 


27.5 


26.9 


25.4 


21.4 


16.8 


16.3 


14.7 


14.0 


12.9 


12.5 


11.8 


Black 


39.9 


27.8 


27.8 


28.5 


22.8 


18.3 


17.9 


16.1 


15.5 


14.3 


14.1 


13.4 



NA Not available. 

1 Represents deaths of infants under 1 year old, exclusive of total deaths. 

2 Per 100,000 live births from deliveries and complications of pregnancy, childbirth, and the puerperium Deaths for 1979 calculated according to the ninth revision of the 
International Classification of Diseases, for the earlier years calculated according to the revision in use at the time, see text, p. 57 

3 Beginning 1970, includes only those deaths with stated or presumed period of gestation of 20 weeks or more; for prior years. Includes gestational age not stated. 
"Represents deaths of infants under 28 days old, exclusive of fetal deaths. 

Source: U.S. National Center for Health Statistics, Vital Statistics of the United States, ? and unpublished data. Most of the data taken from U.S. Bureau of the Census. Statistical 
Abstract of the U.S., 1982-1983 U.S. Government Printing Office, Washington, DC December, 1982 Table 111, p. 75. and National Center tor Health Statistics Advance 
Report, Final Mortality Statistics, 1980 and 1981, Vol. 32, No. 4S (DHHS Pub No (PHS) 83-1120) and Vol. 33, No 3 (DHHS Pub No. (PHS) 84-1120) and unpublished Fetal 
Mortality Data. 



67 



Table 6 

Infant mortality rates by age for Indians and Alaska Natives and United States, all races. 
(rates per 1 ,000 live births) 





Infant 




Neonatal 






Postneon 


Calendar Year 


Mortality 


0-27 


Under 


1-6 


7-27 


28-36^ 




Rate 


Days 


1 Day 


Days 


Days 


Days 


Indians and Alaska Natives 














1977-1979 


1 5.5 


7.8 


3.9 


2.5 


1 .3 


7.6 


1 Q7fi-1 Q7fi 


1 6.4 


8.2 


4.4 


2.5 


1 .3 


8.2 


1 Q7C.-1 Q77 


1 7.7 


8.8 


4.8 


2.7 


1 .3 


8.9 


1074.-1075 


18.7 


9.2 


5.1 


2.8 


1 .3 


9.5 


1073.1075 


18.8 


9.2 


4.8 


3.0 


1 .4 


9.6 


1972-1974 


19.7 


9.3 


5.0 


2.9 


1.4 


10.4 


1971-1973 


21.9 


10.3 


5.8 


3.0 


1.4 


11.0 


19/0-19/^ 


22. 1 


1 -1 r\ 
1 1 .0 


O.O 


2.9 


1 c 

1 .0 


1 1 .b 


1969-1971 


24.6 


12.2 


6.8 


3.6 


1.8 


12.3 


1968-1970 


27.0 


12.9 


7.0 


3.9 


2.0 


14.1 


1967-1969 


30.0 


14.3 


7.8 


4.5 


2.0 


15.7 


1966-1968 


34.0 


15.7 


8.4 


4.9 


2.3 


18.4 


1965-1967 


36.8 


16.1 


8.6 


5.1 


2.4 


20.7 


U.S. All Races 














1 978 


13.8 


9.5 


5.1 


2.9 


1 .5 


4.3 


1 977 


14.1 


9.9 


5.3 


3.1 


1 .5 


4.2 


1 976 


15.2 


10.9 


5.9 


3.1 


1 .6 


4.3 


1 975 


16.1 


1 1 .6 


6.3 


3.7 


1 .6 


4.5 


1974 


16.7 


12.3 


6.7 


3.7 


1 .6 


4.4 


1 Q7^ 


17 7 


n n 

1 o.u 


7 9 


4 9 


1 ^ 


A 7 


1972 


18.5 


13.7 


8.1 


4.3 


1.3 


4.8 


1971 


19.1 


14.2 


8.2 


4.6 


1.4 


4.9 


1970 


20.0 


15.1 


8.8 


4.8 


1.5 


4.9 


1969 


20.9 


15.6 


9.2 


4.9 


1.5 


5.3 


1968 


21.8 


16.1 


9.5 


5.1 


1.5 


5.7 


1967 


22.4 


16.5 


9.6 


5.3 


1.6 


5.9 


1966 


23.7 


17.2 


10.0 


5.6 


1.6 


6.5 



'Source: Monthly Vital Statistics Report, NCHS, Vol 29, No. 6, September 17, 1980, and neonatal by age— unpublished from NCHS. 
Taken from FY 1984 Budgeted Appropriation Indian Health Service "Chart Series" Tables Vital Events Branch, Office of Program 
Statistics, Division of Resource Coordination. Indian Health Service. Rockville, MD, April, 1982 



Table 7 

Asian infant mortality rate in the United States and percent of all U.S. 
infant deaths, 1979. 



Race Group 


Infant Mortality 
Rate, 1979 


Percent of U.S. 
Infant Deaths, 1979 


Chinese 


5.9 


0.15 


Japanese 


4.6 


0.08 


Filipino 


3.8 


0.12 


Other Asians 


8.3 


0.67 



Source: National Center for Health Statistics: Vital Statistics of the United States, 1 979 
Volume II, Mortality, Part A DHHS Publication No (PHS) 84-1 1 01 . Public Health Serv- 
ice, Washington, DC. U S Government Printing Office, 1984 



68 



Table 8 

Selected major causes of infant mortality in the United States, 1971 and 1979 

(per 100,000 live births) 1 



Condition/Disease 




1 971 2 






19793 




Total 


White 


Other 


Total 


White 


Other 


Congenital Anomalies 


299.8 


309.9 


253.8 


255.4 


259.5 


238.3 


SIDS 


NA 


NA 


NA 


151.1 


124.2 


260.9 


Respiratory Distress Syndrome 


127.0 


116.9 


173.7 


156.2 


142.3 


213.0 


Complications of Pregnancy 


149.0 


146.7 


205.8 


46.4 


37.9 


81.2 


Asphyxia of Newborn 


230.2 


204.4 


348.9 


31.7 


27.1 


50.1 


Immaturity Unqualified 


207.7 


170.4 


379.0 








Disorders relating to short 














gestation and low birthweight 








100.0 


75 6 


200.2 



NA Not available. 

These data may not be completely comparable because of changes in the Classification of Diseases 
2 From the 8th Revision of the International Classification of Diseases. 
3 From the 9th Revision of the International Classification of Diseases. 

Source: National Center for Health Statistics: Vital Statistics of the United States, 1979 Volume II, Mortality, Part A DHHS Publication 
No (PHS) 84-1101 Public Health Service. Washington, DC U S Government Printing Office. 1984. 



Table 9 

Asian neonatal and postneonatal mortality rates in the United 
States, 1979. 





Mortality Rates, 1979 


Racial Group 


Neonatal 


Postneonatal 


Chinese 


3.3 


2.6 


Japanese 


3.4 


1.2 


Filipino 


2.6 


1.2 


Other Asian 


5.5 


2.8 



Source: National Center for Health Statistics Vital Statistics of the United States, 
1979 Volume II, Mortality, Part A. DHHS Publication No. (PHS) 84-1 101 Public 
Health Service. Washington, DC. U S Government Printing Office, 1984 



69 



Table 10 

Percent of infants of low birthweight, by race: United States, 
1950-1980. 



Year 


All 
races 


White 


All other races 
Total Black 


1 own 
i you 


fi ft 

D.O 




11.5 


12.5 


1 Q7Q4 


fi Q 

D.J 


fi ft 
0 . 0 


11.6 


12.1 


1 Q7ft 


7 1 

/ . I 


fi Q 


11.9 


12.9 


1 Q77 


7 1 


fi Q 


11.9 


12.8 


1 Q7R 


7 ft 


fi 1 


12.1 


13.0 


1 Q7S 


7 4 


fi ft 


12.2 


13.1 


1 Q74 


7 4 


fi ft 


12.4 


13.1 


1 Q7ft 


7 fi 


R A 


12.5 


13.3 


1 Q7? 


7 7 

1 t 


fi fi 


12.9 


13.6 


1 Q71 


7 7 


fi R 


12.7 


13.4 


1 Q70 


7 Q 


fi ft 


13.3 


13.9 


1 QRQ 


P, 1 
O. 1 


7 n 


13.5 


14.1 


1 Qfift 


ft ? 


7 1 


13.7 


— 


1 Qfi7 


ft ? 


7 1 


13.6 


— 


1 Qfifi 


ft ft 


7 ? 


13.9 


— 


1 Qfi 1 ^ 


ft ft 
O.O 


7 ? 


13.8 


— 


1 QfiA 


ft 9 


7 -1 


13.9 


— 


1 Qfifti 


ft ? 


7 -1 


13.6 


— 


1 Qfi?i 




7 n 


13.1 


— 


1 Qfi1 


7 ft 
/ . 0 


fi Q 


13.0 


— 


1 QfiD 


7 7 


fi ft 


12.8 






7 7 


fi ft 


12.9 




1 QSR2 


7 7 


fi ft 

0 . 0 


12.9 




19572 


7.6 


6.8 


12.4 




1956 2 


7.5 


6.7 


12.0 




19552' 3 


7.6 


6.8 


11.7 




195423 


7.4 


6.8 


11.3 




1953 23 


7.6 


7.0 


11.3 




195223 


7.6 


7.0 


11.1 




195123 


7.5 


7.0 


10.7 




195Q2' 3 


7.5 


7.1 


10.2 





'Figures by color exclude data for residents of New Jersey. 
2 Excludes data for Massachusetts. 
3 Excludes data for Connecticut. 

"Definition changed from under 2501 grams to under 2500 grams. 
Source: National Center for Health Statistics: Advance report of final natality 
statistics, 1980. Monthly Vital Statistics Report, Vol 31, No 8, supp. DHHS Pub., 
No. (PHS) 83-1120 Public Health Service, Hyattsville, MD, November 1982. Table 
1. p.24 



Table 11 



Births of low birthweight (under 2,500 grams) 1 


and percent low birthweight, by age of mother, Indians 


Cu ILJ r^lc5or\Cl 1 NdU VCo 


in reservation States, and United States, all races. 








Indians & 


Alaska Natives 1977-1979 


U.S 


All Races, 


1978 


Age of 


Total 


Number 


Percent 


Total 


Number 


Percent 


Mother 


Live Births 


Low Weight 


Low Weight 


Live Births 


Low Weight 


Low Weight 


All Ages 


89,898 


5,865 


6.5 


3,333,279 


236 342 


7.1 


Under 20 years 


22,555 


1,589 


7.0 


554,179 


55,148 


10.0 


20-24 years 


33,281 


2,063 


6.2 


1,139,524 


80,699 


7.1 


25-29 years 


20,408 


1,187 


5.8 


1,015,183 


60,319 


6.0 


30-34 years 


9,431 


675 


7.2 


474,318 


28,693 


6.1 


35-39 years 


3,332 


263 


7.9 


126,196 


9,465 


7.5 


40 years and over 


891 


88 


9.9 


23,879 


2,018 


8.5 



1 Starting in 1979 the International Classification of Diseases (ICD-9) revised the definition of low birthweight to births of under 2,500 
grams. Previously the definition had been 2,500 grams or less. 1977 and 1978 low birthweight data presented above reflect the 
previous definition. 

Source: FY 1984 Budgeted Appropriation Indian Health Service "Chart Series" Tables. Vital Events Branch, Office of Program 
Statistics, Division of Resource Coordination. Indian Health Service, Rockville, MD, April, 1982 



Table 12 

Percent distribution of live births by birthweight and percent low birthweight, by Hispanic origin of mother, 
and by race of child for mothers of non-Hispanic origin: Total of 22 reporting States, 1980 



Origin of mother 



Birthweight 








Hispanic 






Non-Hispanic 














Central 


Other and 










All 






Puerto 




and South 


unknown 










origins 1 


Total 


Mexican 


Rican 


Cuban 


American 


Hispanic 


Total 2 


White 


Black 


Total 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


Less than 500 grams 


0.1 


0.1 


0.1 


0.1 


0.1 


0.1 


0.1 


0.1 


0.1 


0.2 


500-999 grams 


0.4 


0.4 


0.3 


0.5 


0.4 


0.4 


0.3 


0.4 


0.3 


1.0 


1,000-1,499 grams 


0.6 


0.5 


0.5 


0.7 


0.5 


0.5 


0.6 


0.6 


0.5 


1.2 


1,500-1,999 grams 


1.3 


1.1 


1.1 


1.7 


1.1 


1.0 


1.1 


1.4 


1.1 


2.5 


2,000-2,499 grams 


4.4 


4.0 


3.6 


6.0 


3.5 


3.8 


4.8 


4.5 


3.7 


7.6 


2,500-2,999 grams 


16.7 


16.9 


15.8 


22.6 


15.7 


16.3 


19.5 


16.8 


14.6 


24.4 


3,000-3,499 grams 


37.4 


39.3 


38.9 


40.2 


39.5 


40.7 


39.7 


37.1 


36.5 


38.4 


3,500-3,999 grams 


28.6 


28.3 


29.4 


22.5 


29.5 


28.2 


26.3 


28.6 


31.1 


19.6 


4,000-4,499 grams 


8.6 


7.8 


8.4 


4.9 


8.2 


7.7 


6.3 


8.7 


9.9 


4.2 


4,500-4,999 grams 


1.6 


1.4 


1.6 


0.7 


1.3 


1.2 


1.0 


1.6 


1.9 


0.7 


5,000 grams or more 


0.2 


0.2 


0.3 


0.1 


0.2 


0.2 


0.3 


0.2 


0.3 


0.1 


Percent low birth- 






















weight 3 


6.9 


6.1 


5.6 


8.9 


5.6 


5.8 


7.0 


7.0 


5.7 


12.5 



1 1ncludes origin not stated. 

2 lncludes races other than white and black. 

3 Weight of less than 2,500 grams (5 lbs. 8 oz) 

Source: National Center for Health Statistics, S.J. Ventura, "Births of Hispanic Parentage, 1980." Monthly Vital Statistics Report, Vol. 32, 
No. 6 Supp. DHHS Pub. No. (PHS) 83-1120. Public Health Service, Hyattsville, MD, September 1983. Table 14, p 16. 



Table 13 



Total fertility rates and birth rates by age of mother, by race of child: United States, 1970-80 

(Total fertility rates are sums of birth rates for 5-year-age groups multiplied by 5, Birth rates are live births per 1 ,000 women in specified group, enumerated as of April 1 
for 1970 and 1980 and estimated as of July 1 for all other years) 



Age of mother 



Year and race of child 


lotai 
fertility 
rate 


10-14 
years 


Total 


15-19 years 
15-17 
years 


18-19 
years 


on 0 a 
20-24 

years 


25-29 
years 


30-34 
years 


35-39 
years 


40-44 
years 


45-4$ 
year; 


All races 
























19801 


1,839.5 


1.1 


53 0 


32.5 


82.1 


1 15.1 


112.9 


61.9 


19.8 


3.9 


0.2 


1 979 1 


1 ,808.0 


1 2 


52.3 


32.3 


81 .3 


1 12.8 


111.4 


60.3 


1 9.5 


3.9 


0.2 


1978 1 


1,760.0 


1.2 


51.5 


32.2 


79.8 


109.9 


108.5 


57.8 


19.0 


3.9 


0.2 


19771 


1,789.5 


1 2 


52.8 


33.9 


80.9 


112.9 


111.0 


56.4 


19.2 


4.2 


0.2 


1976 1 


1,738.0 


1.2 


52.8 


34.1 


80.5 


1 10.3 


106.2 


53.6 


19.0 


4.3 


0.2 


1975' 


1,774.0 


1.3 


55.6 


36.1 


85.0 


113.0 


108.2 


52.3 


19.5 


4.6 


0.3 


1974 1 


1,835.0 


1 2 


57.5 


37,3 


88.7 


1 17.7 


111.5 


53.8 


20.2 


4.8 


0.3 


1973 1 


1,879.0 


1.2 


59.3 


38.5 


91.2 


1 19.7 


112.2 


55.6 


22.1 


5.4 


0.3 


1972 1 


2,010.0 


1.2 


61.7 


39.0 


96.9 


130.2 


117 7 


59.8 


24.8 


6.2 


0.4 


1971 2 


2,266.5 


1.1 


64.5 


38.2 


105.3 


150.1 


134.1 


67.3 


28.7 


7.1 


0.4 


1970 2 


2,480.0 


1.2 


68.3 


38.8 


114.7 


167.8 


145.1 


73.3 


31.7 


8.1 


0.5 


White 
























1980 1 


1,748.5 


0.6 


44.7 


25.2 


72.1 


109.5 


112.4 


60.4 


18.5 


3.4 


0.2 


19791 


1 ,715.5 


0.6 


43.7 


24.7 


71 .0 


107.0 


1 10.8 


59.0 


18.3 


3.5 


0.2 


1978 1 


1,667.5 


0.6 


42.9 


24.9 


69.4 


104.1 


107.9 


56.6 


17.7 


3.5 


0.2 


1977 1 


1,703.0 


0 6 


44.1 


26.1 


70.5 


107.7 


110.9 


55.3 


18.0 


3.8 


0.2 


1976 1 


1,652.0 


0 6 


44.1 


26.3 


70.2 


105.3 


105.9 


52.6 


17.8 


3.9 


0.2 


1975 1 


1,686.0 


0.6 


46.4 


28.0 


74,0 


108.2 


108.1 


51.3 


18.2 


4.2 


0.2 


1974 1 


1,748.5 


0 6 


47.9 


28.7 


77.3 


113.0 


111.8 


52.9 


18.9 


4.4 


0.2 


1973' 


1,783.0 


0.6 


49,0 


29.2 


79.3 


1 14.4 


112.3 


54.4 


20.7 


4.9 


0.3 


1972 1 


1,906.5 


0.5 


51.0 


29.3 


84.3 


124.8 


117.4 


58.4 


23.3 


5.6 


0.3 


19712 


2,160.5 


0.5 


53.6 


28.5 


92.3 


144.9 


134.0 


65.4 


26.9 


6.4 


0.4 


1970 2 


2,385.0 


0.5 


57.4 


29.2 


101.5 


163.4 


145.9 


71.9 


30.0 


7.5 


0.4 


All other 
























1980 1 


2,323.0 


3.9 


94.6 


68.3 


133.2 


145.0 


1 15.5 


70.8 


27.9 


6.5 


0.4 


19791 


2,309.5 


■ 1 1 


96.5 


70.5 


134.9 


144.3 


1 14.6 


68.3 


27.3 


6.4 


0.4 


1978' 


2,264.5 


4.0 


96.0 


70.4 


134.4 


142.1 


111.9 


65.2 


26.9 


6.4 


0.4 


1977' 


2,278.5 


4.3 


99.5 


74,8 


136.8 


142.3 


111.5 


63.4 


27.3 


6.9 


0.5 


1976' 


2,222.5 


4.3 


99.9 


75.5 


137.2 


138.9 


107.6 


59.5 


26.9 


6.9 


0.5 


1975' 


2,276.0 


4.7 


106.4 


80.5 


146.1 


141.0 


108.7 


58.8 


27.6 


7.5 


0.5 


1974' 


2,338.5 


4.6 


111.3 


84,9 


153.1 


145.5 


109.5 


59.9 


28.8 


7.6 


0.5 


1973' 


2,443.0 


5.0 


117.5 


90,5 


160.9 


151.6 


111.2 


63.2 


30.9 


8.6 


0.6 


1972' 


2,627.5 


4.7 


123.8 


93.8 


173.3 


163.4 


1 19.3 


68.9 


34.8 


9.9 


0.7 


19712 


2,919.5 


4.7 


128.5 


94.0 


185.6 


184.0 


134.6 


79.3 


40.2 


11.7 


0.9 


19702 


3,066.7 


4.8 


133.4 


95.2 


195.4 


196.8 


140.1 


82.5 


42.2 


12.6 


0.9 


Black 
























1980' 


2,266.0 


4.3 


100.0 


73.6 


138.8 


146.3 


109.1 


62 9 


24 5 


5.8 


0.3 


1979' 


2,263.2 


■1 6 


101.7 


75.7 


140.4 


146.3 


108.2 


60.7 


24.7 


6.1 


0.4 


1978' 


2,218.0 


4.4 


100.9 


75.0 


139.7 


143.8 


105.4 


58.3 


24.3 


6.1 


0.4 


1977' 


2,251.0 


4.7 


104.7 


79.6 


142.9 


144.4 


106.4 


57.5 


25.4 


6.6 


0.5 


19761 


2,187.0 


4.7 


104.9 


80.3 


142.5 


140.5 


101.6 


53.6 


24 8 


6.8 


0.5 


19751 


2,243.0 


5.1 


111.8 


85.6 


152.4 


142.8 


102.2 


53 1 


25.6 


7.5 


0.5 


19741 


2,298.5 


5 0 


116.5 


90.0 


158.7 


146.7 


102.2 


54.1 


27.0 


7.6 


0.6 


19731 


2,411.0 


5.4 


123.1 


96.0 


166.6 


153.1 


103.9 


58.1 


29.4 


8.6 


0.6 


19721 


2,601.0 


5.1 


129.8 


99.5 


179.5 


165.0 


112.4 


64.0 


33.4 


9.8 


0.7 


19712 


2,902.0 


5.1 


134.5 


99.4 


192.6 


186.6 


128.0 


74.8 


38.9 


11.6 


0.9 


19702 


3,098.7 


5.2 


147.7 


101.4 


204.9 


202.7 


136 3 


79.6 


41 9 


12.5 


1.0 



1 Based on 100 percent of births in selected States and on a 50-percent sample of births in all other States, see Technical notes. 
2 Based on a 50-percent sample of births 

Note: Rates for 1971-79 have been revised: see Technical notes. 

Source National Center for Health Statistics: Advance report of final natality statistics, 1980. Monthly Vital Statistics Report, Vol. 
31. No 8, supp DHHS Pub , No (PHS) 83-1120 Public Health Service, Hyattsville, MD, November 1982 Table 4, p 13 



72 



Table 14 

Percent distribution of live births in the United States by live 
birth order, 1980. 







I ivp Rirth Ordpr 
(Parity) 




Group 


1 


2-3 




All Races 


42.8 


46.6 


10.6 


White 


43.5 


46.8 


9.7 


Other 


39.6 


45.3 


15.1 


Black 


39.3 


45.2 


15.0 


Hispanic 


37.8 


45.4 


16.8 



Source: National Center for Health Statistics: Monthly Vital Statistics Reports: 
Advance. Final Natality Characteristics 1980, Vol. 31, No 8S, 11/30/82 and 
Births of Hispanic Parentage, 1980, Vol. 36, No. 6S, 9/23/83 



Table 15 

Births to unmarried women, by race and age of mother: 1950 to 1980. 

[Prior to 1960, excludes Alaska and Hawaii. Beginning 1970, excludes births to nonresidents of U S Includes estimates for States in which marital status data were not 
reported. No estimates included for misstatements on birth records or failures to register births. See Historical Statistics, Colonial Times to 1970, series B 28-35] 



RACE AND AGE OF MOTHER 


1950 


1955 


1960 


1965 


1970 


1975 


1976 


1977 


1978 


1979 




NUMBER (1,000) 
























Total live births 


141.6 


183.3 


224.3 


291.2 


398.7 


447.9 


468.1 


515.7 


543.9 


597.8 


665.7 


White 


53.5 


64.2 


82.5 


123.7 


175.1 


186.4 


197.1 


220.1 


233.6 


263.0 


320.1 


Black and other 


68.1 


119.2 


141.8 


167.5 


223.6 


261.6 


271.0 


295.5 


310.2 


334.8 


345.7 


Black 


(NA) 


(NA) 


(NA) 


(NA) 


215.1 


249.6 


258.8 


281.6 


293.4 


315.8 


325.7 


Under 15 years 


3.2 


3.9 


4.6 


6.1 


9.5 


11.0 


10.3 


10.1 


9.4 


9.5 


9.0 


15-19 years 


56.0 


68.9 


67.1 


123.1 


190.4 


222.5 


225.0 


239.7 


239.7 


253.2 


262.8 


20-24 years 


43.1 


55.7 


68.0 


90.7 


128.7 


134.0 


145.4 


168.6 


186.5 


210.1 


237.3 


25-29 years 


20.9 


28.0 


32.1 


36.8 


40.6 


50.2 


55.4 


62.4 


70,0 


80.6 


99.6 


30-34 years 


10.8 


16.1 


18.9 


19.6 


19.1 


19.8 


21.0 


23.7 


26.5 


31.3 


41.0 


35 years and over 


7.7 


10.7 


13.6 


15.1 


12.4 


10.4 


10.9 


11.1 


11.7 


13.1 


16.1 


BIRTH RATE 1 
























Total 2 


14.1 


19.3 


21.6 


22.5 


28.4 


24.6 


24.7 


26.0 


26.2 


27.8 


29.4 


White 2 


6.1 


7.9 


9.2 


11.6 


13.8 


12.6 


12.7 


13.7 


13.9 


15.1 


17.6 


Black and other 2 


71.2 


87.2 


98.3 


97.6 


89.9 


80.4 


78.1 


79.4 


78.7 


80.9 


77.2 


Black 2 


(NA) 


(NA) 


(NA) 


(NA) 


95.5 


85.6 


83.2 


84.5 


83.1 


85.3 


82.9 


15-19 years 


12.6 


15.1 


15.3 


16.7 


22.4 


24.2 


24.0 


25.5 


25.4 


26.9 


27.6 


20-24 years 


21.3 


33.5 


39.7 


39.9 


38.4 


31.6 


32.2 


34.7 


36.1 


36.7 


40.9 


25-29 years 


19.9 


33.5 


45.1 


49.3 


37.0 


28.0 


27.5 


28.5 


29.4 


31.0 


34.0 


30-34 years 


1 : • 


22.0 


27.8 


37.5 


27.1 


18.1 


17.8 


17.2 


17.3 


1 : 2 


21.1 



NA Not available. 

1 Rate per 1,000 unmarried women (never-married, widowed, and divorced). 
2 Covers woman aged 15-44 years. 

Source: National Center for Health Statistics: Vital Statistics of the United States, annual, and unpublished data. National Center 
for Health Statistics: Advance report of final natality statistics, 1980. Monthly Vital Statistics Report, Vol. 31, No. 8, Supp DHHS 
Pub. No. (PHS) 83-1120. Public Health Service, Hyattsville, Md, November 1982. Table 15, p 25 and Table 16, pp. 26-27. In U S 
Bureau of the Census, Statistical Abstract of the United States: 1982-1983 U.S. Government Printing Office. Washington, DC, 
December, 1982. Table 97, p. 66. 



73 



Table 16 

Number and rate of births to unmarried women, by age and Hispanic origin of mother, and by race of child for mothers of non-Hispanic 
origin: Total of 22 reporting States, 1980. 

Origin of mother 
Hispanic Non-Hispanic 



Age of mother All ^ Centra , other and 

origins 1 j ota | Mexican Rj can Cuban and South unknown Total 2 White Black 

American Hispanic 



Number 



All ages 


399,272 


72,531 


43,822 


15,593 


713 


5,769 


6,634 


300,803 


115,467 


175,205 


Under 15 years 


5,324 


821 


551 


184 


3 


16 


67 


4,233 


1,034 


3,121 


15-19 years 


152,474 


23,924 


15,470 


5,049 


220 


877 


2,308 


119,287 


47,350 


68,636 


15 years 


12,899 


1,965 


1,267 


436 


18 


42 


202 


10,269 


3,393 


6,654 


16 years 


23,966 


3,799 


2,507 


794 


31 


102 


365 


18,683 


7,198 


1 1 ,049 


17 years 


33,795 


5,219 


3,443 


1,080 


41 


155 


500 


26,560 


10,721 


15,062 


18 years 


39,947 


6,166 


3,969 


1,303 


59 


244 


591 


31,352 


12,717 


17,754 


19 years 


41,867 


6,775 


4,284 


1,436 


71 


334 


650 


32,423 


13,321 


18,117 


20-24 years 


141,655 


25,475 


15,433 


5,485 


244 


1,967 


2,346 


107,080 


40,909 


62,637 


25-29 years 


62,053 


12,734 


7,123 


2,795 


132 


1,540 


1,144 


44,828 


16,401 


26,555 


30-34 years 


26,890 


6,457 


3,513 


1,441 


68 


928 


507 


18,388 


7,045 


10,409 


35-39 years 


8,891 


2,530 


1,400 


528 


38 


353 


211 


5,719 


2,223 


3,161 


40 years and over . . 


1,985 


590 


332 


111 


8 


88 


51 


1,268 


505 


686 










Rate 


per 1,000 unmarried women^ 








15-44 years 3 


30.3 


52.0 


54.5 


74.5 


9.3 


40.9 




27.7 






15-19 years 


29.1 


39.7 


41.8 


62.4 


6.6 


27.0 




27.7 






1 5-17 years 


21.7 


28.3 


29.9 


43.9 


4.3 


18.6 




20.8 






18-19 years 


41.4 


60.5 


63.9 


96.8 


10.6 


41.1 




39.0 






20-24 years 


42.5 


76.5 


79.5 


114.1 


14.0 


58.6 




38.7 






25-29 years 


34.2 


71.1 


72.0 


94.8 


14.8 


64.2 




30.2 






30-34 years 


22.0 


53.9 


56.2 


64.8 


1 1.4 


49.3 




18.5 






35-44 years 4 


6.9 


19.6 


22.0 


22.3 


4.1 


17.2 




5.5 







'Includes origin not stated 

includes races other than white and black. 

3 Rates computed by relating total births to unmarried mothers, regardless of age of mother, to unmarried women 15-44 years. 
4 Rates computed by relating births to unmarried mothers aged 35 years and over to unmarried women aged 35-44 years. 
Note: Population data to compute rates for non-Hispanic women by race are not available: see Technical notes. 

Source: National Center for Health Statistics, S.J. Ventura. Births of Hispanic Parentage, 1980. Monthly Vital Statistics Report, Vol 32, No 6, Supp. DHHS Pub. No. 
(PHS) 83-1120 Public Health Service, Hyattsville, MD, September 1983. Table 11, p. 14 



74 



Table 17 

Live births by month of pregnancy prenatal care began and race of child: United States, 1980 

[Based on 100 percent of births in selected States and on a 50-percent sample of births in all other States; see Technical notes] 



Race 
of 

child 



Total 



Month of pregnancy prenatal care began 



1st and 3d 4th 5th 6th 7th 8th gth No No , 

2d month month month month month month month P renatal stated 
month care 



All races 1 3,612,258 1,812,854 867,071 350,229 189,800 112,311 73,122 43,010 18,072 46,211 99,578 

White 2,898,732 1,540,198 701,759 257,389 130,604 76,297 49,918 29,438 12,309 28,627 72,193 
Black 589,616 219,121 136,718 79,871 51,163 30,759 19,171 10,858 4,499 15,459 21,997 

'Includes races other than white and black 

Source: National Center for Health Statistics: Advance report of final natality statistics, 1980. Monthly Vital Statistics Report, Vol. 31, No. 8, Supp. DHHS Pub. 
No. (PHS) 83-1120. Public Health Service, Hyattsville, MD, November, 1982. Table 21, p 32. 



Table 18 

Percent distribution of live births by month of pregnancy prenatal care began and median number of prenatal visits, by 
Hispanic origin of mother, and by race of child for mothers of non-Hispanic origin: Total of 22 reporting States, 1980 



Origin of mother 



Measure 
of 

prenatal 
care 


All 
origins 1 






Hispanic 






Non-Hispanic 


Total 


Mexican 


Puerto 
Rican 


Cuban 


Central 
and 
South 
American 


Other 
and 
unknown 
Hispanic 


Total 2 


White 


Black 


Month of pregnancy 








Percent distribution 










prenatal care 






















began 






















Total 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


1 st and 2nd month . . 


50.2 


36.9 


36.1 


32.3 


62.9 


35.5 


42.5 


52.3 


56.2 


37.6 


3d month 


24.5 


23.4 


23.6 


22.8 


19.8 


23.2 


23.9 


24.7 


25.1 


23.5 


4th-6th month 


19.4 


27.8 


28.5 


28.7 


13.4 


28,1 


24.4 


18.1 


15.2 


29.3 


7th-9th month 


4.2 


8.2 


8.5 


7.9 


2.8 


8.2 


7.5 


3.6 


2.7 


6.4 


No prenatal care 


1.6 


3.8 


3.4 


8.3 


1.0 


5.0 


1.7 


1.3 


0.8 


3.2 


Prenatal visits 3 










Median 










Number 4 


11.0 


9.5 


9.3 


9.2 


11.4 


9.6 


1 0 0 


11 1 


11.4 


10.5 



1 1ncludes origin not stated 

includes races other than white and black. 

3 Excludes data for California and New Mexico, which did not report number of prenatal visits. 
4 Excludes births to mothers with no prenatal care. 

Source: National Center for Health Statistics, S.J. Ventura, Births of Hispanic Parentage, 1980. Monthly Vital Statistics Report, Vol 32, No 6 Supp DHHS 
Pub. No. (PHS) 83-1120. Public Health Service, Hyattsville, MD, September 1983. Table 13, p. 15. 



Table 19 

Hospital births and births attended by physicians as a percent of all births by race. 



Characteristic 


1940 


1950 


1960 


1970 


1975 


1980 


Births in hospital 


55.8 


88.0 


96.6 


99.4 


98.7 


99.0 


White 


59.9 


92.8 


98.8 


99.7 


98.9 


99.0 


Other 


26.7 


57.9 


85.0 


97.8 


98.1 


99.1 


Black 


NA 


NA 


NA 


NA 


NA 


99.1 


Births attended by physician 


85.8 


95.1 


97.8 


99.5 


99.1 


97.2 


White 


96.4 


98.7 


99.5 


99.8 


99.2 


97.4 


Other 


50.8 


82.8 


88.5 


98.0 


98.7 


96.3 


Black 


NA 


NA 


NA 


NA 


NA 


96.6 



NA Not available 

Source: Vital Statistics of the U.S., Vol. 1 , Natality et al. In "The Demography of Maternal and Child Health" In Maternal and Child 
Health Practices Problems Resources and Methods of Delivery, Wallace, H.M., Gold, E.M., Oglesby, AC, (eds.) John Wiley and 
Sons, 1982 p. 96. 



Table 20 

Number and percent distribution of family planning visits for females by selected characteristics, according to race and Hispanic origin: 
United States, 1980. 

Race Hispanic origin Race Hispanic origin 

All All 

Non- . Non- 
races races 1 
Selected Characteristics White Black Hispanic Hispanic White Black Hispanic Hispanic 

Number in thousands Percent distribution 

All visits 9,261 6,529 2,540 1,168 8,093 100.0 100.0 100.0 100.0 100.0 

Education 

Less than 12 years 3,692 2,613 1,007 725 2,967 39.9 40.0 39.6 62.1 36.7 

12 years 3,647 2,476 1,100 334 3,313 39.4 37.9 43.3 28.6 40.9 

13 years or more 1,921 1,440 433 108 1,813 20.7 22.1 17.0 9.2 22.4 

Student status 

Student 2,496 1,712 737 118 2,379 27.0 26.2 29.0 10.1 29.4 

Not a student 6,764 4,817 1,803 1,050 5,715 73.0 73.8 71.0 89.9 70.6 

Public assistance income 

Family receives public assistance 

income 1,313 607 680 149 1,164 14.2 9.3 26.8 12.8 14.4 

Family does not receive public 

assistance income 7,948 5,922 1,860 1,019 6,929 85.8 90.7 73.2 87.2 85.6 

Initial visits 1,779 1,373 350 227 1,552 100.0 100.0 100.0 100.0 100.0 

Education 

Less than 12 years 814 616 175 142 672 45.7 44.8 50.1 62.4 43.3 

12 years 619 480 119 64 555 34.8 35.0 33.9 28.1 35.8 

13 years or more 347 277 56 22 325 19.5 20.2 16.0 9.5 20.9 

Student status 

Student 672 504 150 41 631 37.8 36.7 42.8 18.0 40.7 

Not a student 1,108 870 200 186 921 62.2 63.3 57.2 82.0 59.3 

Public assistance income 

Family receives public assistance 

income 213 116 88 25 187 12.0 8.4 25.2 11.2 12.1 

Family does not receive public 

assistance income 1,587 1,257 262 202 1,365 88.0 91.6 74.8 88.8 87.9 

Return visits 7,481 5,156 2,190 940 6,541 100.0 100.0 100.0 100.0 100.0 

Education 

Less than 12 years 2,879 1,997 832 583 2,295 38.5 38.7 38.0 62.0 35.1 

12 years 3,028 1,996 982 271 2,758 40.5 38.7 44.8 28.8 42.2 

13 years or more 1,575 1,163 377 86 1,488 21.0 22.6 17.2 9.2 22.8 

Student status 

Student 1,825 1,209 587 77 1,748 24.4 23.4 26.8 8.2 26.7 

Not a student 5,657 3,947 1,603 863 4,794 75.6 76.6 73.2 91.8 73.3 

Public assistance income 

Family receives public assistance 

income 1,100 491 592 123 977 14.7 9.5 27.0 13.1 14.9 

Family does not receive public 

assistance income 6,381 4,664 1,598 817 5,564 85.3 90.5 73.0 86.9 85.1 

'Includes visits for races other than white and black 
Note. Numbers may not add to totals due to rounding. 

Source: National Center for Health Statistics: B.L Hudson, Basic Data on Visits to Family Planning Service Sites: U.S. 1980 
Vital and Health Statistics, Series 13, No. 68. DHHS Publication No (PHS) 82-1729 Public Health Service, Hyattsville, MD, 
July 1982 Table 4, p 12. 

76 



Table 21 

Contraceptive use by currently married women 15-44 years old, by age, race, and method of contraception: 1965-1976 

[1965 data from National Fertility Survey, 1973 and 1976 data ] 

Total, 15-44 Years 15-29 Years Old 30-44 Years Old 

Race and Method of Contraception 2!^ 

1965 1973 1976 1965 1973 1976 1965 1973 1976 

White Women 

Currently married (1,000) 

Percent using contraception 

Percent distribution of users of contraception 

Wife sterilized 

Husband sterilized 

Pill 

Intra-uterine device 

Diaphragm 

Condom 

Foam 

Rhythm 

All other 

Black Women 



Currently married (1,000) 


2,091 


2,081 


2,169 


(NA) 


964 


993 


(NA) 


1,117 


1,177 


Percent using contraception 


56.2 


60.0 


58.6 


62.2 


63.7 


61.0 


51.1 


56.8 


56.5 


Percent distribution of users of contraception . . 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


Wife sterilized 


15.3 


22.7 


18.7 


7.4 


9.8 


8.6 


23.4 


35.2 


27.9 


Husband sterilized 


.6 1 


1.7' 


3.0 1 


.4 1 


.7 1 


.3 1 


.71 


2.7' 


5.4 


Pill 


21.6 


43.8 


38.0 


30.9 


63.9 


56.0 


12.3 


24.3 


21.5 


Intra-uterine device 


2.8 


12.7 


10.6 


4.8 


13.1 


9.1 


.7 


12.4 


11.9 


Diaphragm 


5.0 


2.01 


3.0 1 


3.3 


1.2 1 


1.4 1 


6.7 


2.8' 


4.5 


Condom 


17.4 


5.3 


7.9 


18.7 


3.1 1 


8.4 


16.0 


7.5 


7.4 


Foam 


6.3 


5.0 


6.5 


8.1 


3.5 


4.9 


4.5 


6.6 


8.0 


Rhythm 


2.6 


1.3 1 


2.4 1 


2.9 


1.6 1 


3.1 1 


2.2 


.9 1 


1.8 


All other 


28.5 


5.3 


10 0 


23.5 


3.1 


8.3 


33.5 


7.6 


1 1.6 



23,427 


24,249 


24,795 


64.1 


70.5 


68.8 


100.0 


100.0 


100.0 


6.5 


11.6 


13.9 


5.5 


11.9 


14.2 


24.0 


35.6 


32.9 


1.11 


9.4 


9.2 


10.4 


3.6 


4.4 


22.4 


14.1 


10.9 


3.1 


5.0 


4.2 


11.5 


4.1 


5.1 


15.5 


4.8 


5.3 



9,166 


10,963 


11,218 


63.4 


70.7 


70.0 


100.0 


100.0 


100.0 


2.8 


5.7 


6.1 


3.2 


5.6 


6.0 


42.4 


52.9 


50.6 


1.51 


11.9 


10.5 


6.6 


2.6 


4.1 


19.2 


10.5 


9.7 


4.5 


5.3 


4.8 


8.0 


2.0 


4.0 


11.9 


3.5 


4.3 



14,261 13,286 13,577 



64 


5 


70.4 


67 


8 


100 


0 


100.0 


100 


0 


8 


7 


16.5 


20 




7 


0 


17.1 


81 


1 


12 


8 


21.2 


17 


8 




81 


7.4 


8 


1 


12 


8 


4.4 


4 


8 


24 


4 


17.1 


11 


9 


2 


2 


4.7 


3 


8 


13 


7 


5.9 


6 


1 


17 


7 


5.9 


6 


1 



NA Not available. 

1 Figure does not meet standards of reliability or precision 

Source; 1) "Trends in Contraceptive Practice: 1965-1973." Family Planning Perspectives, Vol. 8. No. 2, 1976. 2) U.S. Bureau 
of the Census, Statistical Abstract of the United States: 1982-83. U.S. Government Printing Office, Washington, DC, 
December, 1982. Table 100, p. 68 



77 



Table 22 

Legal abortions, by selected characteristics: 1973 to 1980. 

(Number of abortions from surveys conducted by source, characteristics from the U.S. Centers for Disease Control's (CDC) annual abortion surveillance summaries, with 
adjustments for changes in States reporting data to the CDC each year) 

,. Percent Abortion 

Number 1,000 . .... _. .. . 

Distribution Ratio 1 

Characteristic 1973 1974 1975 1976 1977 1978 1979 1980 1973 1975 1980 1973 1979 

Total legal abortions 744.6 898.6 1,034.2 1,179.3 1,316.7 1,409.6 1,497.7 1,563.9 100.0 100.0 100.0 193 297 

Age of women: 

Less than 15 years old ... . 11.6 13.4 15.3 15.8 15.7 15.1 16.2 15.3 1.6 1.5 1.0 476 599 

15-19 years old 232.4 278.3 324.9 382.7 396.6 418.8 444.6 444.8 31.2 31.4 28.6 280 444 

20-24 years old 240.6 286.6 331.6 392.3 449.7 489.4 525.7 549.4 32.3 32.1 35.4 181 304 

25-29 years old 129.6 162.7 188.9 220.5 246.7 266.0 284.2 303.8 17.4 18.2 19.6 126 208 

30-34 years old 72.6 89.8 100.2 110.1 124.4 134.3 142.0 153.1 9.7 9.7 9.6 165 213 

35-39 years old 41.0 48.8 52.7 56.7 61.7 65.3 65.1 66.6 5.5 5.1 4.3 246 322 

40 years old and over 16.8 19.0 20.5 21.3 22.0 20.7 19.9 20.9 2.3 2.0 1.3 334 447 

Race of women: 

White 548.8 629.3 701.2 784.9 888.8 909.4 1,062.4 1,093.6 73.7 67.8 70.4 178 272 

Black and other 195.8 269.3 333.0 394.4 427.9 440.2 435.3 460.3 26.3 32.2 29.6 252 385 

Marital status of women: 

Married 216.2 248.2 271.9 290.0 299.7 350.6 322.2 319.9 29.0 26.3 20.6 74 99 

Unmarried 528.4 650.4 762.3 889.3 1,017.0 1,059.0 1,175.5 1,234.0 71.0 73.7 79.4 564 660 

Number of prior live births: 

None 375.2 482.5 499.3 562.6 742.5 798.1 868.2 900.0 50.4 48.3 57.9 242 365 

1 137.4 155.5 206.8 244.4 249.4 271.3 287.1 304.8 18.5 20.0 19.6 108 201 

2 102.2 130.1 156.6 181.5 186.5 198.0 207.0 215.6 13.7 15.2 13.9 190 279 

3 61.7 70.3 86.8 97.7 80.0 83.3 82.1 82.9 8.3 8.4 5.3 228 399 

4 or more 68.2 60.2 84.4 93.1 58.4 58.9 53.3 50.6 9.1 8.1 3.3 196 256 

No. of prior induced abortions: 

None (NA) 762.1 822.1 911.3 966.7 994.5 1,023.3 1,040.8 (NA) 79.5 67.0 (NA) (NA) 

1 (NA) 112.6 170.4 213.2 267.8 315.5 350.4 371.0 (NA) 16.5 23.8 (NA) (NA) 

2 or 3 (NA) 24.0 41.7 54.7 82.2 99.6 124.0 142.1 (NA) 4.0 9.2 (NA) (NA) 

Weeks of gestation: 

Less than 9 weeks 284.3 399.4 480.6 559.9 657.9 707.8 748.5 800.0 36.2 46.5 51.5 (NA) (NA) 

9-10 weeks 221.6 256.5 290.4 333.8 361.2 388.4 412.9 416.5 29.7 28.1 26.8 (NA) (NA) 

11-12 weeks 130.6 134.9 151.1 171.3 179.5 187.7 203.6 201.8 17.5 14.6 13.0 (NA) (NA) 

13 weeks or more 106.2 107.8 112.1 114.4 118.2 125.7 132.6 136.7 14.6 10.8 8.7 (NA) (NA) 

NA Not available. 

1 Number of abortions per 1,000 abortions and live births For 1980, total abortion ratio is 300. 

Source: 1973-1978, S K. Henshaw. J D Forrest, E Sullivan, and C. Th?, Abortion 1977-1978: Need and Services in the United 
States. Each State and Metropolitan Area. The Alan Guttmacher Institute, New York, NY. 1981 (copyright); 1979-1980: Abortion 
1979-1980: Need and Services in the United States. Each State and Metropolitan Area. AGI, New York, NY. forthcoming. Taken 
from U.S. Bureau of the Census, Statistical Abstract of the U S : 1982-1983, U.S. Government Printing Office, Washington, DC. 

December 1982. Table 101, p 68 National Center for Health Statistics, D Burnham, Ph D: Induced Terminations of Pregnancy: 

Reporting States, 1980. Monthly Vital Statistics Report Vol. 32, No. 85. DHHS Pub. No. (PHS) 84-1 120 PHS, Hyattsville, Md, Dec. 1983. 



78 



Table 23 

Age-specific attack rates (per 100,000 population) for reported cases of primary and secondary syphilis 
in the United States (excluding California and New York), 1967-1979. 



Provider (Race) Men Women 



Year 


\ d- i y 


on oa 


or on 




i o- 1 y 


on oa 


OR OCX 


ou-o» 


Public (White) 


















1967 


1.0 


5.2 


3.7 


2.2 


1.0 


2.3 


1.6 


0.8 


1979 


3.0 


11.7 


12.4 


8.0 


2.4 


2.7 




0.7 


Public (other)* 


















1967 


114.6 


317.6 


249.5 


125.2 


124.1 


183.4 


118.9 


59.5 


1979 


72.0 


214.9 


182.1 


96.9 


62.0 


75.7 


46.5 


23.9 


Private (White) 


















1967 


1.8 


7.4 


6.1 


3.8 


1.4 


3.1 


2.3 


1.2 


1979 


1.2 


4.7 


6.6 


5.7 


1.2 


1.0 


0.7 


0.5 


Private (other) 


















1967 


34.1 


111.9 


99.7 


50.9 


45.6 


82.7 


53.8 


29.6 


1979 


10.6 


28.3 


35.3 


21.5 


11.8 


19.6 


18.7 


9.7 



'This category includes all races other than white. 

Source: "Syphilis in the United States: 1967-1979," Sexually Transmitted Diseases, Fichtner. R.R., Aral, SO. Blount. J H , Zaidi. 
A.A., Reynolds, G., and Darron, W M , 1983: 10: 77-80 Table 1, p. 79. 



Table 24 

Rates for venereal diseases— American Indians and Alaska Natives compared to United States, all races. 

[Rates per 100,000 Population] 



Calendar Year 


Gonorrhea 




Syphilis, All Stages 




IHS 


U.SJ 


IHS 


U.S. 1 


1981 


718.4 


435.2 


72.0 


32.0 


1980 


798.4 


443.3 


78.8 


30.4 


1979 


950.6 


459.5 


68.1 


30.7 


1978 


1,219.9 


468.3 


88.2 


30.0 


1977 


1,393.7 


465.9 


129.2 


30.0 


1976 


1,580.2 


470.4 


166.4 


33.7 


1975 


1,731.7 


469.2 


172.3 


37.7 


1974 


1,667.2 


428.7 


148.7 


52.0 


1973 


1,794.2 


404.9 


149.9 


42.0 


1972 


1,923.6 


371.6 


207.8 


44.2 


1971 


1,647.5 


328.2 


180.5 


47.0 


1970 


1,182.0 


297.5 


172.1 


45.3 


1969 


1,026.6 


268.6 


161.8 


46.3 


1968 


842.3 


235.7 


145.8 


48.8 


1967 


751.7 


207.3 


99.9 


52.5 


1966 


727.8 


181.9 


89.3 


54.4 


1965 


716.6 


169.6 


93.0 


58.9 



'Sexually Transmitted Disease (STD) Statistical Letter, Calendar Year 1981, Centers for Disease Control. PHS, DHHS. 1982; 
and publications in this series for previous years. 

Source: Sexually Transmitted Diseases (STD) Fact Sheet. DHHS, Pub No (CDC) 81-8195, Edition 36, Calendar Year 1980. 
Taken from FY 1984 Budgeted Appropriation Indian Health Service "Chart Series" Tables. Vital Events Branch, Office of Pro- 
gram Statistics, Division of Resource Coordination. Indian Health Service, Rockville, MD, April 1982. 



79 



Table 25 

Age-specific and age-adjusted gonorrhea rates (per 100,000) for white men and women in the 
United States (excluding New York and California), 1967-1979 

Sex, Age 

(Years) 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 



Men 



<14 


1 


1 


1 


2 


2 


2 


3 


3 


3 


3 


3 


3 


4 


15-19 


156 


170 


203 


251 


316 


365 


369 


377 


393 


370 


341 


336 


340 


20-24 


553 


638 


703 


780 


901 


1,004 


1,007 


1,028 


1,060 


1,007 


955 


922 


909 


25-29 


329 


350 


381 


399 


470 


507 


549 


580 


642 


622 


638 


629 


626 


30-39 


118 


128 


133 


145 


163 


174 


183 


198 


229 


238 


251 


250 


255 


40-49 


37 


38 


39 


44 


45 


46 


47 


50 


59 


62 


68 


69 


75 


^50 


13 


13 


13 


14 


14 


15 


14 


17 


18 


19 


20 


20 


21 


Total 




























Unadjusted 


94 


106 


121 


141 


173 


197 


206 


220 


240 


239 


238 


237 


240 


Age-adjusted 


107 


118 


129 


143 


165 


182 


187 


195 


210 


205 


203 


199 


201 


/omen 




























<14 


3 


4 


4 


5 


8 


10 


12 


12 


14 


13 


13 


14 


14 


15-19 


121 


144 


185 


234 


354 


487 


587 


650 


705 


661 


645 


643 


644 


20-24 


178 


202 


237 


295 


383 


542 


686 


757 


802 


744 


723 


692 


692 


25-29 


82 


87 


101 


111 


150 


193 


253 


285 


318 


293 


302 


290 


293 


30-39 


27 


31 


31 


36 


46 


62 


76 


79 


88 


88 


86 


82 


83 


40-49 


8 


9 


10 


10 


12 


15 


17 


18 


19 


18 


19 


19 


19 


>50 


3 


3 


3 


3 


4 


4 


5 


6 


6 


6 


5 


5 


5 


Total 




























Unadjusted 


38 


44 


54 


67 


95 


131 


164 


184 


201 


191 


189 


185 


186 


Age-adjusted 


36 


41 


48 


58 


80 


109 


136 


II') 


161 


151 


149 


145 


145 



Source: "Gonorrhea in the United States: 1967-1979," Sexually Transmitted Diseases, Zaidi, A, A,, Aral, S O , Reynolds, G.H.. 
Blount, J H , Jones, O.G., Fichtner, R.R , 1983:10: 72-76 Table 1, p, 73. 



80 



Table 26 

Age-specific and age-adjusted gonorrhea rates (per 100,000) for nonwhite men and women in the United States (excluding New 

York and California), 1967-1979. ________ 

Sex, Age (Years) 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 



Men 



<14 


33 


42 


44 


51 


50 


56 


56 




57 


57 


56 


55 


53 


53 


15-19 


4,223 


4,551 


5,121 


5,295 


5,322 


5,559 


5,724 


5 


772 


5,687 


5,326 


4,958 


4,71 1 


4,446 


20-24 


1 1 ,578 


1 2,984 


13,967 


1 4,007 


13,600 


13,693 


12,780 


13 


1 73 


13,991 


13,225 


1 2,678 


1 1 ,853 


10,809 


25-29 


7,430 


7,570 


7,877 


7,760 


7,825 


8,012 


8,184 


8 


651 


9,073 


8,487 


8,487 


8,154 


7,543 


30-39 


2,750 


2,866 


2,950 


2,989 


2,947 


2,992 


2,960 


3 


092 


3,266 


3,1 72 


3,193 


3,077 


2,942 


40-49 


810 


81 7 


834 


835 


813 


816 


804 




836 


894 


888 


870 


886 


832 


>50 


186 


181 


204 


202 


205 


201 


219 




231 


266 


256 


292 


275 


250 


Total 






























Unadjusted 


2,059 


2,237 


2,495 


2,654 


2,733 


2,876 


2,872 


3 


025 


3,228 


3,144 


3,1 12 


3,002 


2,819 


Age-adjusted 


2,385 


2,549 


2,714 


2,728 


2,695 


2,742 


2,695 


2 


794 


2,926 


2,776 


2,715 


2,587 


2,404 


'omen 






























<14 


50 


56 


66 


80 


82 


100 


130 




144 


163 


158 


147 


158 


165 


15-19 


1,852 


2,090 


2,414 


2,608 


2,948 


3,854 


5,161 


5 


683 


5,980 


6,084 


6,024 


6,268 


6,099 


20-24 


2,586 


2,767 


3,163 


3,252 


3,465 


4,365 


5,792 


6 


341 


6,648 


6,694 


6,594 


6,643 


6,264 


25-29 


1,351 


1,318 


1,526 


1,532 


1,597 


2,040 


2,589 


2 


698 


2,954 


2,799 


2,808 


2,874 


2,756 


30-39 


446 


455 


479 


501 


501 


632 


809 




836 


882 


801 


785 


798 


765 


40-49 


113 


112 


100 


106 


113 


133 


161 




190 


187 


185 


158 


159 


154 


>50 


35 


25 


40 


33 


34 


46 


49 




63 


75 


55 


50 


52 


47 


Total 






























Unadjusted 


573 


626 


739 


802 


889 


1,159 


1,555 


1 


723 


1,852 


1,873 


1,864 


1,922 


1,847 


Age-adjusted 


551 


581 


660 


688 


737 


94 1 


1 232 


1 


338 


1,418 


1,399 


1 377 


1,409 


1,853 



Source: "Gonorrhea in the United States: 1967-1979," Sexually Transmitted Diseases, Zaidi. A, A., Aral, SO, Reynolds, G.H., 
Blount, J.H., Jones, OG , Fichtner, R R , 1983 10 72-76 Table 1 , p 73 



81 



Table 27 

Estimated frequency of selected genetic disorders 

Number Per 

Genetic Type Examples Million Births 

I. Single gene 17,412 
Autosomal dominants 9,555 

Brachydactyly 6 

Muscular atrophy 40 

Deaf mutism 46 

Retinoblastoma 58 

Marfan's syndrome 20 

Osteogenesis imperfecta 20 

Achondroplasia 100 

Autosomal recessives 1 ,260 

Albinism 130 

Alkaptonuria 5 

Galactosemia 50 

Ichthyosis 10 

Hemoglobinopathy 200 

Phenylketonuria 60 

Cystic fibrosis 60 

Sex-linked recessives 397 

Hemophilia A 20 
Duchenne progressive 

muscular dystrophy 50 

Sex-linked dominants 6,200 

Glucose-6-phosphate 

dehydrogenase deficiency 6,000 

Vitamin D resistant rickets 50 

II. Chromosomal abnormalities 5,000 
Autosomal 2,500 

Down's syndrome 1,600 

Trisomy D 230-450 

Trisomy G 690 

Trisomy E 230 

Sex 2,500 

Klinefelter^ (XXY) 1,000 

XYY 690 

Turner's (XO) 230 

XO 230 



82 



Table 27 






References 


Estimated frequency of selected genetic disorders— Continued 




1 . Burton, L, Smith, H., and 
Nichols, A.: Public Health 






Number Per 


Genetic Type 


Examples 


Million Births 


and Community Medicine. 
Williams and Wilkins, 








III. Complex malformations 




o.n nnn 


Baltimore, 1980. 




Cardiac Defects 


r nnn 


2. Pratt, M.: "The 




Strabismus 


o ^nn 


Demography of Maternal and 




Clubfoot (Talipes equinovarus) 




Child Health" in Maternal 




Idiopathic scoliosis 


o nnn 


and Child Health Practices: 




Anencephaly 


i , / CJU 


Problems, Resources, and 




Cleft palate and/or harelip 


1 ~7f\{~\ 


Methods of Delivery. Wallace, 




Spina bifida and meningocele 


Q/in 


H., Gold, E., Oglesby, A., 




Congenital dislocation of hip 


DO / 


(eds). John Wiley and Sons, 




Hydrocephalus 


oyu 


New York, 1982. 




Digestive tract anomalies 


a on 


3. Public Health Service: Pro- 




Genito urinary tract anomalies 


T^n 


moting Health/Preventing 




Congenital cataract 


I / u 


Disease: Objectives for the 




Skin anomalies 


1 U 


Nation. Office of the Assistant 




Congenital amputations 


AO 


Secretary for Health, U.S. 


IV. Incompatibilities 




a onn 
4,^UU 


Department of Health and 




Erythroblastosis 


a onn 


Human Services, Fall 1980. 




Auto-immune disease 


7 


4. Public Health Service: 


V. Polygenic traits 


Allergic conditions 


ooU.UUU 


"Promoting Health/Preventing 




Ron nnn 


Disease: Public Health Serv- 




Hypertension 


^nn non 

OUU,UuU 


ice Implementation Plans for 




Duodenal ulcers 


i nn nnn 
1 UU,UUU 


Attaining the Objectives of 




Mental retardation 


on nnn 


the Nation," PHS 83-50193A 




Pyloric stenosis 


o nnn 


(USPS 324-990), Public 




Gout 




Health Reports, Supplement 




Schizophrenia 


^ nnn 

1 ,uuu 


to the September-October 




Epilepsy 


500 


1983 Issue. 




Diabetes mellitus 


130 


5. National Center for Health 




Deafness 


100 


Statistics: Vital Statistics of the 




Cystic fibrosis 


60 


United States, Volume II. 


Source: Cunningham, G. in Maternal and Child Health Practices Problems, Resources and Methods of Delivery. Eds: 


Mortality, Part A. 1971-1979. 


Wallace, H., Gold, E., and Oglesby, A., 1982 






6. Madans, J., Kleinman, J., 
and Machlin, S.: "Differences 
Among Hospitals as a Source 
of Excess Neonatal Mortality: 
The District of Columbia, 
1970-1978." Journal of Com- 
munity Health. Vol. 7, No. 2. 
Winter 1981. 

7. Health Planner's Hand- 
book: Section II B. Infant and 
Perinatal Mortality Rates for 
the U.S., States and 
Counties. December 1984. 
Section II G. Annual Infant 
and Perinatal Mortality Rates 
for Major U.S. Cities, June 
1983 and, Section II D. An- 
nual Infant and Perinatal Mor- 
tality Rates for States, June 
laoo. rratt, M. Information 
Sciences Research Institute. 
December 1984. 

8. Chase, H.: "Trends in 








Low Birth Weight Ratios, 



83 



United States and Each 
State, 1950-1968." U.S. 
Department of Health, Educa- 
tion, and Welfare, Public 
Health Service. Pub. No. 
(HSM) 73-5117. U.S. Govern- 
ment Printing Office, 
Washington, DC, June 1973. 

9. Foster, J.E., and Klein- 
man, J.C.: NCHS, Adjusting 
Neonatal Mortality Rates for 
Birthweight. Vital and Health 
Statistics, Series 2, No. 94. 
DHHS Pub. No. 82-1368. 
Public Health Service. United 
States Government Printing 
Office, Washington, DC, 
September 1982. 

10. Taffel, S.: "Factors 
Associated with Low Birth- 
weight, United States, 1976." 
Vital and Health Statistics, 
Series 21, Number 37. 
DHEW Pub. No. (PHS) 
80-1915. Public Health Serv- 
ice. Hyattsville, MD, April 
1980. 

11. Kessel, S.S., et al.: The 
changing pattern of low birth- 
weight in the U.S., 1970 to 
1980. Journal of American 
Medical Association, April 20, 
1984, Vol. 251, No. 15. 
1984. 

12. Brazie, J., Pratt, M., et 
al.: Selected natality 
characteristics for single live 
births, U.S., 1974. DHEW 
Pub. No. (HSA) 79-5744. 
Public Health Service. United 
States Government Printing 
Office, Washington, DC. 
1979. 

13. Stickle, G.: "The Health 
of Mothers and Babies: How 
Do We Stack Up?" Address 
presented at the Fifth Na- 
tional Volunteer Leadership 
Conference, National Foun- 
dation of the March of 
Dimes, New Orleans, 
December 1 , 1976. 

14. Stickle, G., and Ma, P.: 
"Some Social and Medical 
Correlates of Pregnancy Out- 
come," American Journal of 
Obstetrics and Gynecology, 
Vol. 127, No. 2. January 15, 
1977. 



15. Reed, D.M., and Stanley, 
F., eds.: The Epidemiology of 
Prematurity. Baltimore Urban 
and Schwarzenberg, Inc., 
1977. 

16. The Rand Corporation: 
Algorithms for Health Plan- 
ners. Vol. 2, Infant Mortality, 
by L.J. Harris, E. Keeler, and 
M.E. Michnich. R 2215/ 
2HEW. Santa Monica, CA. 
The Rand Corporation, 
August, 1977. 

1 7. National Center for 
Health Statistics: A study of 
infant mortality from linked 
records by birth weight, 
period of gestation, and other 
variables, United States, 1960 
live-birth cohort, by R.J. Arm- 
strong. Vital and Health 
Statistics, Series 20, No. 12. 
DHEW Pub. No. (PHA) 
79-1055. Public Health Serv- 
ice. U.S. Government Printing 
Office, Washington, DC. May 
1972. 

18. Hemminski, E., and Star- 
field, B.: Prevention of Low 
Birthweight and Pre-Term 
Birth. Milbank Memorial Fund 
Quarterly/Health and Society. 
56(3): 339-361, 1978. 

19. Shapiro, S., McCormick, 
M., Starfield, B., et al.: 
Relevance of Correlates of In- 
fant Deaths for Significant 
Morbidity at 1 Year of Age. 
Am. J. Public Health. 136(3): 
363-373, February 1980. 

20. Eisner, V., Pratt, M , et 
al.: The Risk of Low Birth- 
weight. Am. J. Public Health. 
69(9): 887-893, September 
1979. 

21 . National Center for 
Health Statistics, Carroll, M., 
et al.: Dietary Intake Source 
Data, U.S. 1976-1980. Vital 
and Health Statistics, Series 
11, No. 231. DHHS Pub. No. 
(PHS) 83-1681. PHS. United 
States Government Printing 
Office, Washington, DC, 
March 1983. 

22. National Center for 
Health Statistics: Advance 
Report of Final Natality 
Statistics, 1980. Monthly Vital 
Statistics Report, Vol. 31, No. 



8. supp. DHHS Pub. No. 
(PHS) 83-1120. Public Health 
Service, Hyattsville, MD, 
November 1982 and Ad- 
vance Report of Final Natality 
Statistics, 1981. Ibid. Vol. 32, 
No. 95S. 

23. Lincoln, R.: "Teenage 
Pregnancy and Childbearing: 
Why the Differences between 
Countries?" Family Planning 
Perspectives, Vol. 15, No. 3, 
May-June 1983. 

23a. Jones, E.F., Forest, 
J.D., et al.: Teenage 
Pregnancy in Developing 
Countries: Determinants and 
Policy Implications. Family 
Planning Perspectives, Vol. 
17, No. 2. March/April 1985. 

24. National Center for 
Health Statistics: Monthly Vital 
Statistics Reports, Births of 
Hispanic Parentage, 1980, 
Vol. 32, No. 65. 1983. 

25. Mosher, W., and Pratt, 
W.: "Reproductive Im- 
pairments Among Married 
Couples: United States." Vital 
and Health Statistics, Public 
Health Service. U.S. Govern- 
ment Printing Office, 
Washington, DC, December 
1982. 

26. Lesser, A.: "Trends in 
Maternal and Child Health" 
In Maternal and Child Health 
Practices, Problems, and 
Resources, and Methods of 
Delivery. Wallace, H., et al 
(eds.). Illinois, 1973. 

27. Cypress, B.K.: "Office 
Visits by Women," Vital and 
Health Statistics, Series 13, 
No. 45. DHEW Pub. No. 
(PHS) 80-1796. Hyattsville, 
MD. March 1980. 

28. U.S. Bureau of the Cen- 
sus: Statistical Abstract of the 
United States, 1982-1983. 
U.S. Government Printing Of- 
fice, Washington, DC, 
December 1982. 

29. Marieskind, H.I.: Women 
in the Health System, Pa- 
tients, Providers, and Pro- 
grams. The C.V. Mosby 
Company, St. Louis, 1980. 



30. Cutler, J.C.: "The 
Prevention of Sexually 
Transmitted Disease," to be 
published. 

31 . Fiuemara, N.J., and 
Calhoun, J.: "Multiple Sexual- 
ly Transmitted Diseases," 
Sexually Transmitted 
Diseases. W.B. Saunders 
Company, Philadelphia, 
1980. 

32. Youmans, G.P., Pater- 
son, P.Y., and Sommers, 
H.M.: The Biologic and 
Clinical Basis of Infectious 
Diseases. W.B. Saunders 
Company, Philadelphia, 
1980. 

33. Fichtner, R.R., Aral, S.O., 
Blount, J.H., Zaidi, A. A., 
Reynolds, G., and Darron, 
W.M.: "Syphilis in the United 
States: 1967-1979." Sex 
Transm Dis 1983: 10: 72-76. 

34. U.S. Department of 
Health and Human Services: 
Centers for Disease Control. 
STD Fact Sheet. HHS Pub. 
No. (CDC) 81-8195. Atlanta, 
GA. 

35. Zaidi, A., Aral, S., 
Reynolds, G., Blount, J., 
Jones O., and Fichtner, R.: 
"Gonorrhea in the United 
States: 1967-1979." Sex 
Transm Dis 1983: 10: 72-76. 

36. Knox, S.R., Corey, L, 
Blough, H.A., and Lerner, 
M.A.: "Historical Findings in 
Subjects for a High 
Socioeconomic Group who 
have Genital Infections with 
Herpes Simplex Virus." Sex 
Transm Dis 1982: 9: 15-20. 

37. Stavraky, K., Rawls, W., 
Chiavetta, J., Donner, A., 
and Wanklm, J.: "Sexual and 
Socioeconomic Factors Affec- 
ting the Risk of Past Infec- 
tions with Herpes Simplex 
Virus Type 2" American Jour- 
nal of Epidemiology 1 18: 
109-121. 

38. Jaffe, H., Bregman, D., 
and Selik, R.: "Acquired Im- 
mune Deficiency Syndrome 
in the United States: The First 



84 



1000 Cases." J. Inf. Dis. 
148: 2. August 1983. 

39. Center for Disease Con- 
trol: "Prevention of Acquired 
Immune Deficiency Syn- 
drome." Morbidity and Mor- 
tality Weekly Report. Vol. 32, 
No. 8. March 4, 1983. 

40. Center for Disease Con- 
trol: "Acquired Immunodefi- 
ciency Syndrome (AIDS)." 
Morbidity and Mortality 
Weekly Report. Vol. 32, No. 
52. January 6, 1984. 

41. Manual on Terminology 
and Classification in Mental 
Retardation, American 
Association on Mental 
Deficiency. 

42. National Association for 
Retarded Citizens: Facf 
Sheet, February 1974. 

43. Cunningham, G.C.: 
"Genetic Programs." In 
Maternal and Child Health 
Practices: Problems and 
Methods of Delivery. Ibid. 
1982. 

44. "The Health of America's 
Nonwhite Population, Status 
Report and Future Plans for 
Dealing with Diseases More 
Prevalent or Severe in Non- 
whites." Department of 
Health, Office of Program 
Planning and Evaluation, 
November 11, 1971. (Un- 
published document). 

45. Golbus, M., and Laros, 
R.: "Hemoglobinopathies and 
Hemolytic Anemias, In 
Genetic Diseases in 
Pregnancy, Maternal Effects 
and Fetal Outcome, edited 
by Joseph, D., Schulman, J., 
Leigh, J. Simpson Academic 
Press, New York, 1981. 

46. The National Foundation 
of the March of Dimes: Facts: 
1977, 1978. 

47. U.S. Department of 
Health, Education and 
Welfare: "What do you know 
about PKU?" Pub. No. 
(HSM) 73-5703, 1971. 



List of Tables 

1. Maternal mortality rates 
by race. 

2. Maternal deaths and 
rates for Indians and Alaska 
Natives and all races. 

3. Maternal deaths and 
maternal mortality rates for 
selected causes by race: 
United States, 1980. 

4. Infant mortality rates for 
earlier years (1974, 1975, or 
1976) and later years (1979, 
1980, or 1981) for selected 
countries, showing percent 
change between the two 
years cited and annual 
average percent change in 
rate. 

5. Infant, maternal, and 
neonatal mortality rates, and 
fetal mortality ratios, by race: 
1940 to 1981. 

6. Infant mortality rates by 
age for Indians and Alaska 
Natives and United States, all 
races, (rates per 1 ,000 live 
births) 

7. Asian infant mortality 
rates in the United States and 
percent of all U.S. infant 
deaths, 1979. 

8. Selected major causes of 
infant mortality in the United 
States, 1971 and 1979. 

9. Asian neonatal and post- 
neonatal mortality rates in the 
United States, 1979. 

10. Percent of infants of low 
birthweight, by race: United 
States, 1950-1980. 

1 1 . Births of low birthweight 
(under 2,500 grams) and per- 
cent low birthweight, by age 
of mother, Indians and 
Alaska Natives in reservation 
States, and United States, all 
races. 

12. Percent distribution of 
live births by birthweight and 
percent low birthweight, by 
Hispanic origin of mother, 
and by race of child for 
mothers of non-Hispanic 
origin: total of 22 reporting 
States, 1980. 

13. Total fertility rates and 
birth rates by age of mother, 
by race of child: United 
States, 1970-80. 



14. Percent distribution of 
live births in the United 
States by live birth order, 
1980. 

1 5. Births to unmarried 
women, by race and age of 
mother: 1950 to 1980. 

16. Number and rate of 
births to unmarried women, 
by age and Hispanic origin 
of mother, and by race of 
child for mothers of non- 
Hispanic origin: total of 22 
reporting States, 1980. 

17. Live births by month of 
pregnancy prenatal care 
began and race of child: 
United States, 1980. 

18. Percent distribution of 
live births by month of 
pregnancy prenatal care 
began and median number 
of prenatal visits, by Hispanic 
origin of mother, and by race 
of child for mothers of non- 
Hispanic origin: total of 22 
reporting States, 1980. 

19. Hospital births and births 
attended by physicians as a 
percent of all births by race. 

20. Number and percent 
distribution of family planning 
visits for females by selected 
characteristics, according to 
race and Hispanic origin: 
United States, 1980. 

21. Contraceptive use by 
currently married women 
15-44 years old, by age, 
race, and method of con- 
traception: 1965-1976. 

22. Legal abortions, by 
selected characteristics, 1973 
to 1980. 

23. Age-specific attack rates 
(per 100,000 population) for 
reported cases of primary 
and secondary syphilis in the 
United States (excluding 
California and New York), 
1967-1979. 

24. Rates for venereal 
diseases—American Indians 
and Alaska Natives com- 
pared to United States, all 
races. 



25. Age-specific and age- 
adjusted gonorrhea rates (per 
100,000) for white men and 
women in the United States 
(excluding New York and 
California), 1967-1979. 

26. Age-specific and age- 
adjusted gonorrhea rates (per 
100,000) for nonwhite men 
and women in the United 
States (excluding New York 
and California), 1967-1979. 

27. Estimated frequency of 
selected genetic disorders. 

List of Figures 

1 . Maternal death rates. 

2. Infant mortality rates by race: 
United States, 1940-1980. 

3. Annual reported cases in the 
United States (excluding Califor- 
nia and New York) per 1 00,000 
population of primary and 
secondary syphilis by race 
(white and all other), sex, and 
reporting source for 1 967-1 979. 

4. Composition by diagnosis of 
total reported morbidity due to 
syphilis in the United States for 
1960 and 1979. 

5. Reported cases of gonor- 
rhea by race and sex, United 
States (excluding California and 
New York), 1967-1979. 

6. Acquired immunodeficiency 
syndrome (AIDS) cases, by 
quarter of diagnosis— United 
States, first quarter 1980 
through December 19, 1983. 



85 



86 



Chapter IV 



Acute Disease 
Conditions 



Table of Contents 



Overview 89 

A. Introduction 89 

B. Self-Reported Incidence 
of Acute Conditions 89 

C. Medical Care Utilization 
and Health Status 90 

1 . Physician Visits 91 

2. Inpatient Hospitalization 93 

D. Mortality from Acute Conditions 93 
Tables 95 

References 105 
List of Tables 106 



88 



Chapter IV 



Acute Disease 
Conditions 



Overview 

In this chapter, three basic 
types of data were employed 
to measure the impact of 
acute disease conditions on 
the disadvantaged in com- 
parison with the rest of the 
population. The first type of 
data is self-reported acute 
diseases from health inter- 
views. In 1978, blacks 
reported fewer acute condi- 
tions than whites (191.0 con- 
ditions per 100 persons, 
compared with 223.9 condi- 
tions reported by whites). 
However, blacks experienced 
more disability as a result of 
acute conditions than did 
whites. 

The second type of data 
employed for comparative 
purposes is medical care 
utilization data. For the vast 
majority of acute conditions, 
physician visit rates were 
lower for nonwhites than for 
whites in 1979. Some notable 
exceptions, however, were 
found. Nonwhites had twice 
the physician visit rate as 
whites for influenza in 1973. 
Nonwhite females had twice 
the visit rate for pelvic inflam- 
matory disease (PID) as white 
females in 1979. The visit 
rate for acute upper 
respiratory infections (URI's) 
was 14.7 percent higher 
among nonwhites than 
among whites in 1979. 
Hospitalization rates were 
slightly higher for nonwhites 
than for whites for infective 
and parasitic conditions, 
acute upper respiratory con- 
ditions, pneumonia, and 
diseases of the skin and sub- 
cutaneous tissue. 

The third type of data, 
mortality rates, was analyzed 
for the three most frequent 
categories of acute conditions 
causing death: cirrhosis of 



the liver, influenza, and 
pneumonia. The nonwhite-to- 
white ratio of age-adjusted 
death rates from influenza 
and pneumonia was 1.61 in 
1980, which is a con- 
siderable drop from the 1950 
ratio of 2.34. 

Following a period of in- 
crease in mortality rates from 
cirrhosis of the liver, a 
decrease was observed in 
1980. A series of possible ex- 
planations for this drop is 
given, including the possibili- 
ty that more intensive and ex- 
tensive health care services 
have been provided to 
alcoholics as a result of 
changes in insurance 
coverage for these services. 
With regard to racial dif- 
ferences in mortality from cir- 
rhosis, the nonwhite-to-white 
ratio inverted from 0.86 in 
1950 to 1.82 in 1980. 

A. Introduction 

Advances in American 
medicine and public health in 
the first half of the 20th cen- 
tury resulted in substantial 
reductions in morbidity and 
mortality from many acute 
disease conditions. Although 
chronic disease conditions, 
especially heart disease, 
cancer, and stroke, are 
leading causes of death and 
morbidity in the United States 
today, certain acute disease 
conditions continue to be ma- 
jor health problems. 
Pneumonia and influenza, for 
example, are among the 
leading causes of death, and 
upper respiratory infections 
are responsible for a con- 
siderable amount of 
morbidity. 



to that of the total population 
at one point in time and over 
time. Acute disease condi- 
tions that are discussed in 
other chapters will not be 
discussed here. Acute condi- 
tions excluded from this 
chapter are those resulting 
from accidental injuries, den- 
tal conditions, health prob- 
lems surrounding pregnancy 
and childbirth, and sexually 
transmitted diseases. 

Three basically different 
types of measures are 
employed in the following 
analyses in order to compare 
the impact of acute disease 
conditions on the disadvan- 
taged versus the general 
population. First, Section B of 
this chapter presents the in- 
cidence of acute disease 
conditions, as measured by 
responses of individuals in 
the course of health inter- 
views. Second, Section C 
discusses selected medical 
care utilization measures. In 
Section D, the third type of 
measure, mortality data for 
selected acute diseases, is 
employed to compare the 
relative impact of acute 
disease conditions on certain 
segments of the population. 

Additional caveats on the 
interpretation of the data 
presented are contained in 
Chapter I of this book. 

B. Self-Reported Incidence 
of Acute Conditions 

The National Health Interview 
Survey (NHIS) methodology 
defines acute conditions as 
those illnesses and injuries of 
less than three months', 
duration for which medical at- 
tention was sought, or which 
resulted in restricted activity 
(1, 2, 3). Conditions which 
meet the above criteria but 
which are generally con- 
sidered chronic are excluded. 



Those chronic conditions are 
listed in each NCHS Publica- 
tion on acute conditions, as 
are the International 
Classification of Disease (ICD) 
codes for acute conditions 
(1, 2). While these criteria for 
categorizing morbidity condi- 
tions are not totally satisfac- 
tory, and we ourselves ques- 
tion the inclusion of some 
conditions in this chapter, 
there are reasons, no matter 
how tenuous, for following 
conventions somewhat 
established in the literature. 

The medical attention and 
restricted activity criteria (in 
the NHIS acute conditions 
definition noted above) are 
used in part to eliminate very 
minor acute conditions which 
have little or no impact on 
the respondent. The effect of 
these criteria, however, may 
be to introduce a 
socioeconomic bias in the 
data. Persons who lack the 
income to pay for care 
and/or persons who are not 
aware that given symptoms 
require medical care may be 
less likely to obtain care for 
the same type of illness than 
would a less disadvantaged 
person. To remind the reader 
of this potential bias, data 
from this survey source will 
be referred to as "reported" 
incidence. In spite of this 
potential bias, an attempt will 
be made to determine from 
available data the position of 
the disadvantaged vis-a-vis 
total incidence of acute 
disease. 

An estimated 478.0 million 
acute illnesses and injuries 
occurred among the civilian 
noninstitutionalized population 
of the United States during 
1981 (3, p. 2). Although in- 
juries resulting from accidents 
are excluded from this 



89 



chapter since they are 
discussed elsewhere in this 
book, NCHS estimates of 
acute condition incidence in- 
clude injuries. Expressed as 
a population-based rate, an 
estimated 212.4 acute condi- 
tions (illnesses and injuries) 
per 100 persons were 
reported in 1981 (see Table 
1). This rate is not significant- 
ly different from the 1979 rate 
of 215.3 acute conditions per 
100 persons (3, p. 2). Based 
on data from Table 1 , acute 
conditions included in the 
1981 incidence rate are 
distributed among the major 
acute disease categories in 
the following manner: 



Disease Group 

Infective and parasitic 
Respiratory conditions 
Digestive system conditions 
Injuries 

All other acute conditions 
Total 



As shown above and in 
Table 1, respiratory condi- 
tions comprise the bulk of 
acute disease conditions 
(52.7 percent). One of the 
groups excluded from this 
chapter, injuries, comprises 
15.6 percent of all acute 
conditions. 

For both sexes, the in- 
cidence of acute conditions is 
highest among persons 
under 6 years of age and 
decreases substantially with 
age (see Table 1). In 1981 , 
persons 6 years of age and 
under experienced 380.0 
acute conditions per 100 per- 
sons, compared with only 
120.6 conditions per 100 per- 
sons age 45 and over. The 
reported incidence of acute 
disease condition is 9.7 per- 
cent higher among females 
than males. Females reported 
221.9 acute conditions per 
100 persons while males 
reported 202.2 acute condi- 



tions per 100 persons in 
1981. 

While acute disease in- 
cidence data are routinely 
published by NCHS in the 
Vital and Health Statistics 
series, racial breakdowns are 
not published. This prevents 
us from presenting recent 
data on acute conditions by 
demographic variables and 
from analyzing trends on 
such data. Data for 1978 with 
racial breakdowns were 
located from an unpublished 
NCHS source (4), however, 
and are presented in Table 
2. 

In 1978, the reported age- 
adjusted incidence rate of 



Percent 

11.1 
52.7 
4.6 
15.6 
16.0 
100.00 



acute disease was 14.7 per- 
cent higher among whites 
(223.9 acute disease condi- 
tions per 100 persons per 
year) than among blacks 
(191.0 acute disease condi- 
tions per 100 persons per 
year). 

While total reported acute 
disease incidence is lower 
among blacks than among 
whites, the converse is true 
with regard to one group of 
acute disease conditions 
listed in Table 2, namely 
digestive disease conditions. 
The incidence rate of 
digestive disease conditions 
for blacks was 13.3 condi- 
tions per 100 persons, com- 
pared with 9.4 among whites, 
a rate 41.5 percent higher. 

Among the specific acute 
disease conditions listed in 
Table 2, influenza is the 
disease for which both the 
absolute and the relative dif- 
ference between whites and 
blacks appears to be the 
greatest. Whites have a 



reported (age-adjusted) in- 
fluenza incidence rate 79.8 
percent higher than that of 
blacks (52.5 conditions per 
100 persons among whites 
compared with only 29.2 
conditions per 100 persons 
among blacks). 

Age-adjusted rates were 
used in the preceding 
paragraphs to compare the 
incidence of acute disease 
conditions of blacks with 
whites. Unadjusted rates are 
also presented in Table 2. 
While the racial differences 
are smaller using unadjusted 
rates (221.7 versus 199.6) 
than they are using age- 
adjusted rates (223.9 versus 
191.0), blacks still have lower 
incidence rates of acute 
disease conditions when 
rates are not adjusted for 
age. Given the younger age 
distribution of blacks com- 
pared with whites (see 
Chapter II), and the higher in- 
cidence of acute conditions 
at younger ages (see Table 
1), the lower incidence of all 
acute conditions combined 
among blacks is unexpected 
on the basis of age 
characteristics. This racial dif- 
ferential may be partially ex- 
plained, however, by the 
restricted-activity and 
treatment-seeking criteria of 
acute conditions used in the 
National Health Interview 
Survey. 

A comparison of some of 
the consequences of acute 
diseases among the racial 
segments of the population 
lends support to the possibili- 
ty that blacks are more likely 
to report proportionately 
more severe acute condi- 
tions. The restricted-activity, 
bed-disability, and work-loss 
days information found in 
Table 2 may be regarded as 
some indication of the sever- 
ity of a reported acute condi- 
tion. The values for each of 
these measures are higher 



for blacks than for whites. 
Thus, blacks report a lower 
frequency of acute conditions 
but higher disability levels 
associated with such condi- 
tions. Two alternative ex- 
planations suggest 
themselves for this type of 
outcome. One is that the 
data were intentionally biased 
or exaggerated by 
respondents for whatever 
reason: the second is that 
because of a generally 
reduced health status, the 
fewer episodes of acute con- 
ditions that blacks experi- 
enced resulted in more pro- 
tracted disabilities. 

The age-adjusted rate of 
work-loss days reported by 
blacks was 31.0 percent 
higher than that reported by 
whites (480.6 work-loss days 
per 100 persons per year 
among blacks compared with 
366.8 work-loss days among 
whites). The age-adjusted 
rate of bed-disability days 
reported by blacks was 27.2 
percent higher than that 
reported by whites (551.3 
bed-disability days per 100 
persons per year reported by 
blacks compared with 433.3 
bed-disability days per 1 00 
persons per year reported by 
whites). Adjusted for age, 
restricted-activity days were 
3.8 percent higher for blacks 
(1027.1 days), than whites 
(989.7 days). 

C. Medical Care Utilization 
and Health Status 

In this section, selected 
medical care utilization 
measures are compared 
among segments of the 
population in order to ascer- 
tain whether acute disease in- 
cidence has a heavier impact 
on the disadvantaged. The 
basic assumption is that the 
frequency with which in- 
dividuals seek medical care 
for a health problem is an in- 
dication of the level of illness 
among those individuals. 
Because utilization of health 



90 



services for a given symptom 
varies from individual to in- 
dividual and group to group, 
utilization cannot be perfectly 
equated with health status. 
Utilization of health services 
is influenced by many in- 
dividual characteristics, in- 
cluding the ability to pay for 
those services. If utilization of 
health services were 
synonymous with need for 
health services, then any 
observed indifference in 
utilization could confidently 
be interpreted as a difference 
in the incidence of a disease. 

Aday and Andersen (5) 
have extensively addressed 
the relationship between 
health service utilization and 
health status. They have 
created a measure which 
relates utilization of health 
services to the need for 
health services, and have 
observed that measure 
among various groups. 
Called the use-disability ratio, 
it is the ratio of two 
measures, a utilization 
measure divided by an illness 
or health-care-needs 
measure. Although not a 
perfect index, the use- 
disability ratio is an attempt 
to assess differential health 
service utilization among per- 
sons with similar health care 
needs. A higher ratio means 
greater utilization of health 
services relative to health 
needs. As expected, the use- 
disability ratio was found to 
be higher for whites than 
racial minorities in several 
applications. 

Any observed differences 
in medical pare utilization 
may be interpreted in at least 
two ways. For example, if 
group A visits a physician 
more frequently than group B 
for acute disease Z, this oc- 
currence may be interpreted 
as follows: 

1. The incidence of acute 
disease Z is higher in group 
A than in group B. The 



observed physician utilization 
differential approximates the 
incidence differential. 

2. The incidence of acute 
disease Z is not higher in 
group A than in group B. 
The observed physician 
utilization differential approx- 
imates an unmet health 
needs differential. 

In this section, utilization 
measures will be interpreted 
for the most part as a proxy 
measure of incidence and 
therefore as health status 
measures. When there is 
reason for doubt, utilization 
measures will be interpreted 
as possible areas of unmet 
health needs. 
1. Physician Visits 
Data relating to physician 
visits discussed in this section 
are of two types: NHIS data 
obtained from the consumer 
of health care (or a sur- 
rogate), and National Am- 
bulatory Medical Care Survey 
(NAMCS) data obtained from 
physician providers of health 
care. 

According to NHIS data, 
in 1971, 81.4 percent (6, p.1) 
and in 1980, 84.4 percent (7, 
p. 26) of all visits to a physi- 
cian were for diagnosis and 
treatment of a condition. The 
distribution of reported visits 
for acute conditions, chronic 
conditions, and no condition 
were as follows (6, 8, 7): 



Acute % 

1971 46.4 
1975 44.0 
1980 44.2 



In Table 3, the proportions 
of office-based physician 
visits by race are presented 
for 1973, the inception year 
of NAMCS, and again for 
1979 for four selected condi- 
tions. As a proportion of visits 
for all conditions combined 
(both chronic and acute), 
visits for the selected acute 
conditions shown in Table 3 
are similar for nonwhites and 



whites with the exception of 
influenza. When rates per 
population were calculated 
and the ratio of the rates of 
nonwhites to whites was 
calculated, some differences 
were seen (see Table 3). 

Nonwhites had over twice 
the visit rate of whites for in- 
fluenza in 1973. Data pertain- 
ing to influenza were not 
published by race for 1979. 
For all other conditions, 
however, visit rates for non- 
whites are lower than those 
for whites, and greater 
disparities are observed in 
1979 than 1973. For exam- 
ple, visit rates among non- 
whites for infective and 
parasitic diseases were only 
9 percent lower than those of 
whites for that condition in 
1973, but 34 percent lower in 
1979. Visit rates for 
respiratory conditions among 
nonwhites were 10 percent 
lower than among whites in 
1973, but 30 percent lower in 
1979. 

Changes in the ICD codes 
between 1973 and 1979 may 
be responsible for some of 
the observed differences over 
time, but it is likely that 
coding changes did not af- 
fect one racial group any 
more than any other, and 
that the differences noted are 
real. 

Table 4 presents 1979 an- 



No Condition 
Reported % 

3.6 
5.4 
4.6 



nual visit rates per 1,000 per- 
sons by principal diagnoses 
(chronic and acute) and by 
race. For the majority of the 
diagnoses listed, visit rates 
are higher for whites than for 
nonwhites. Among the 53 
diagnoses listed in Table 4, 
visit rates are higher for non- 



whites than for whites for 
only seven diagnoses, and 
only three of these were 
acute conditions: 

1 . sprains and strains of 
joints and adjacent muscles: 

2. inflammatory disease of 
female pelvic organs; and 

3. acute upper respiratory 
infections (URI's) of multiple 
or unspecified sites. 

The annual visit rate for 
sprains and strains of joints 
and adjacent muscles was 63 
visits per 1,000 population 
among whites and 67 visits 
per 1,000 population among 
nonwhites. Because injuries 
from accidents are treated 
more fully in Chapter VI of 
this book, this discussion will 
focus on conditions 2 and 3 
above. 

Nonwhite females had 
twice the physician visit rate 
as white females for pelvic in- 
flammatory disease (PID) in 
1979 (96 visits per 1,000 per- 
sons among nonwhites com- 
pared with 48 visits per 
1 ,000 persons among 
whites). Since office-based 
physician visits do not in- 
clude outpatient department 
and emergency room visits, 
the racial differential may be 
even greater than that shown 
by these rates. 

"Pelvic inflammatory 
disease is an important 
public health problem 
because it is a common con- 
dition associated with signifi- 
cant acute and chronic mor- 
bidity and long-term com- 
plications." (9, p. 124) The 
long-term complications of 
PID include recurrent 
episodes due to low-grade in- 
fection, pelvic adhesions, or 
damage to Fallopian tubes. 
In addition, about 25 percent 
of women with one or more 
episodes of PID experience 
aftereffects of the inflamma- 
tions, such as chronic pelvic 
pain, infertility, and ectopic 
pregnancy (9, p. 123). 



Chronic % 

50.0 
50.6 
51.2 



91 



"Epidemiologic and 
clinical evidence strongly 
suggests that sexually 
transmitted diseases are a 
major cause of PID." (9, p. 
120) PID is also strongly 
associated with contraceptive 
intrauterine device use (par- 
ticularly the Dalkon shield) 
and with abortion (9, p. 122). 
An estimated 5,000 cases of 
PID per year in the United 
States during the late 1970's 
have been attributed to abor- 
tion (9, p. 122). Since those 
events or factors associated 
with PID are increasing in the 
United States (see Chapter 
III), PID incidence will prob- 
ably increase in the near 
future. 

Acute upper respiratory in- 
fections (URI's) are another 
disease group listed in Table 
4 for which nonwhites had 
higher physician visit rates 
than whites. They were the 
fourth leading cause of visits 
to physicians in 1979, mak- 
ing up 2.7 percent of all visits 
(10, p. 41). They were ex- 
ceeded in frequency only by 
visits for essential hyperten- 
sion (4.2 percent), normal 
pregnancy (4.0 percent), and 
general medical examination 
(3.0 percent). In 1973, URI's 
were the fifth leading cause 
of visits, making up 3.3 per- 
cent of all visits. They were 
exceeded in frequency by 
medical and special examina- 
tion (6.1 percent), medical 
and surgical after-care (5.0 
percent), prenatal care (3.9 
percent), and essential 
benign hypertension (3.5 per- 
cent) (11, p. 26). 

The visit rate for acute 
URI's was 14.7 percent 
higher among nonwhites (78 
visits per 1 ,000 persons) than 
among whites (68 visits per 
1,000 persons) in 1979 (see 
Table 4). Table 5 contains 
additional information from 
NAMCS regarding URI visits 
in 1980. If drug mention rates 



may be considered an in- 
dicator of severity, acute 
URI's seen by office-based 
physicians are not very dif- 
ferent among blacks and 
whites. (12, pp. 2,3) ("Drug 
mention" refers to the order- 
ing or providing of a drug at 
the time of the visit.) The 
drug intensity rate (drug men- 
tions divided by drug visits) 
was also the same for whites 
and blacks. In 1980, 88.8 
percent of URI visits were 
made by whites, and 11.2 
percent by blacks (nonwhite 
races other than black are 
excluded from these calcula- 
tions), roughly matching their 
proportions in the overall 
population (see Table 5). 

Both Tables 4 and 5 con- 
tain NAMCS data regarding 
URI's. Several differences 
between the two tables, 
however, may explain the 
observation of a higher visit 
rate among nonwhites than 
whites in Table 4, while 
similar visit rates obtain for 
blacks and whites in Table 5. 
The different data years and 
different racial groupings may 
have contributed minimally, 
but the more likely explana- 
tion involves URI grouping 
differences between those 
two tables. Only one ICD URI 
code is included in Table 4 
(465), while three ICD URI 
codes are included in Table 
5 (460, 461, and 465) (12, p. 
33). The diseases which coin- 
cide with these three ICD 
codes are 460, acute 
nasopharyngitis (common 
cold); 461, acute sinusitis; 
and 465, acute upper 
respiratory infections of multi- 
ple or unspecified sites. 
Table 4, in which higher visit 
rates were observed among 
nonwhites, does not include 
the less severe diagnosis 
460, the common cold, while 
Table 5 does. 

Otitis media is not one of 
the conditions listed in Table 
4 for which nonwhites have 
had higher physician visit 



rates than whites (see Table 
4). It was selected for discus- 
sion in this chapter, however, 
because it is an acute 
disease condition with a very 
high incidence among 
another disadvantaged seg- 
ment of the population, 
American Indians and Alaska 
Natives (who form a small 
subgroup of the all nonwhite 
group). 

Otitis media is an inflam- 
mation of the middle ear that 
may be either an acute or a 
chronic condition. In about 
77 percent of the total visits 
for otitis media to physicians 
in 1980, the condition was 
described as acute according 
to NAMCS data (12, p. 33). 

Otitis media was the 
eighth leading diagnosis in all 
visits to office-based physi- 
cians in 1979 (10, p. 41), 
and the 10th leading 
diagnosis for visits in 1973 
(11, p. 26). It was also the 
basis of a larger proportion 
of visits for all diagnoses 
combined, 2.3 percent of all 
visits in 1979, and 1.6 per- 
cent in 1973. 

Table 6 presents otitis 
media physician visits by 
age, race, and drug men- 
tions. In 1980, 95.5 percent 
of all visits were made by 
whites, and only 4.5 percent 
by blacks, a disproportionate- 
ly low rate for blacks (non- 
white races other than black 
are excluded from this 
calculation). 

As previously mentioned, 
the incidence of otitis media 
is especially pronounced 
among another disadvan- 
taged group of concern in 
this book, the American In- 
dian (13, 14). Otitis media is 
a reportable condition among 
American Indians. Because it 
is not a reportable condition 
in the general population, 
however, trends over time in 
the total population and 
among other racial minorities 



could not be compared with 
those among Indians in the 
past. Recent NAMCS data, 
however, provide racial 
breakdowns that can be 
used for some comparative 
purposes. The rate of physi- 
cian office visits for otitis 
media in 1979 among whites 
was 71 per 1 ,000 population, 
which is considerably higher 
than that experienced by 
nonwhites, 36 per 1,000 
population (see Table 4). The 
white otitis media visit rate of 
71 per 1,000 population in 
1979, on the other hand, was 
considerably lower than new 
cases reported by American 
Indians and Alaska Natives 
2 years previously, 1 1 1 per 
1,000 population in 1978 
(see Table 7). 

The rate of otitis media 
among American Indians and 
Alaskan Natives has been in- 
creasing steadily at least 
since the 1962 data 
presented in Table 7, in- 
cluding particularly higher 
rates during 1972 and 1973. 
There does appear to be a 
leveling off of rates in the last 
years tabled, however. Over 
the last 5 years tabled 
(1974-1978), there was a 
1.3 percent increase in otitis 
media rates, whereas over 
the first 5 years tabled 
(1962-1966) the increase was 
81.6 percent. The increases 
over time may represent in- 
creases in the incidence of 
the condition or more fre- 
quent reporting of the condi- 
tion. If the latter is true, it 
may have resulted from an 
increase in use of medical 
care for this condition among 
this group. 

Since otitis media is com- 
monly a complication 
resulting from an upper 
respiratory condition (15), the 
higher rate of otitis media 
among American Indians 
may be due to the higher in- 
cidence of upper respiratory 
infections among this group 
(15, p. 46). It may also be 



92 



Nonwhite-to-White Ratio 



of Rates 

1968 1979 

Infective and parasitic 1.40 1.18 

Acute upper respiratory .79 1.09 

Pneumonia 1.14 1.09 

Diseases of the skin and 

subcutaneous tissue 1.14 1.14 



that the lower levels of health 
care for URI's are enhancing 
otitis media rates. Although 
this affords us a tentative 
hypothesis for the higher in- 
cidence of this condition 
among American Indians, it 
does not explain the lower in- 
cidence of otitis media 
among blacks. 

The high incidence of un- 
treated otitis media may be 
resulting in a high frequency 
of chronic ear disease 
among American Indians (15, 
16). In addition, since it has 
been contended that about 
50 percent of all cases of 
deafness can be traced to 
otitis media (17, p. 504), 
higher rates of deafness may 
be expected among 
segments of the population 
with a high incidence of otitis 
media. Since data concern- 
ing hearing problems may be 
confounded by industrial and 
urban noise environmental 
problems, we do not think 
we can at this time analyze 
the problem further. 
2. Inpatient Hospitalization 
Hospitalization patterns were 
analyzed to determine what 
differences, if any, existed in 
hospital utilization rates for 
acute conditions by race. 
Table 8, giving hospital 
utilization for selected acute 
conditions by race for 1968 
and 1979, shows only slight 
differences between the racial 
groups. 

When rates per 1 ,000 
population were calculated, 
nonwhites were found to 
have higher hospitalization 
rates than whites for the 
same conditions. Those con- 
ditions are presented below, 
along with the ratio of 
nonwhite-to-white rates per 
1,000 population in 1968 and 
in 1979. 



Since race was not stated for 
13 percent of the patients 
disharged in 1979 (18, p. 8), 
the racial differences may not 
be statistically significant but 
are presented to point the 
way for further investigation. 

D. Mortality from Acute 
Conditions 

For some years now, the 
combined categories of 
pneumonia and influenza, 
both acute disease condi- 
tions, have ranked as the fifth 
leading cause of death after 
heart disease, cancer, stroke, 
and accidents. Age-adjusted 
pneumonia and influenza 
death rates by race and sex 
for the United States from 
1950 to 1980 are presented 
in Table 9. 

Death rates from these 
joint causes have a tendency 
to be cyclical, probably due 
to the cyclical nature of in- 
fluenza. The rate for the total 
population in 1950, for 
example, was 26.2, per 
100,000 population. In 1953, 
the rate was 26.3; in 1957, it 
was 27.9; in 1960, it was 
28.0; in 1963, it was 27.7; 
and in 1968, it was 26.8. 
These rates make it appear 
that the mortality rate from 
these causes was constant 
over this 18-year period, 
even though there was a 
definite and constant 
downward trend in the years 
in between those years listed 
above. The apparent rise in 
rates in 1960, for example, is 
an artifact of this cyclical 
characteristic. Although the 
rate in 1960 was 28.0, the 



rate had previously de- 
creased to 23.4 in 1959, and 
then continued the decline in 
1961, when it dropped to 
22.1. 

In the 30-year period 
covered by Table 9, the 
death rate from this cause 
decreased overall by almost 
51 percent, and the rate 
declined more for females 
and for nonwhites. In 1950, 
the nonwhite-to-white ratio 
was 2.34 for males, and by 
1980 that ratio had dropped 
to 1.61; for females, the 1950 
nonwhite-to-white ratio was 
2.68, and it dropped to 1.27 
by 1980. The decrease in 
death rates from influenza 
and pneumonia was more 
precipitous in the last of 
these 3 decades (see the last 
row in Table 9), particularly 
for males. At these rates of 
convergence, the female dif- 
ferential could disappear by 
the end of this decade, and 
the male differential could 
disappear by the end of the 
century. 

Influenza and pneumonia 
are acute disease conditions, 
but the contributing factors to 
deaths from pneumonia are 
sometimes chronic in nature, 
including pre-existing lung 
disease and general debilita- 
tion. Debilitated persons may 
also be more susceptible to 
influenza, and the disease 
may also be more severe in 
people with chronic illness. It 
may be that the change in 
death rates noted above is 
due to a lessening of chronic 
conditions among nonwhites. 
The decline in death rates 
among nonwhites may also 
be due to an increase in 



utilization of the health care 
system, and in fact a very 
slight increase in office visits 
did occur among nonwhites 
(see Table 3). 

Cirrhosis of the liver was 
the sixth leading cause of 
death in the United States in 
1979, and provisional data in- 
dicate that it was tied for fifth 
place in 1980. 

Although a certain amount 
of confusion surrounds 
classification of this condition 
into the acute or chronic 
rubies, it is included in this 
chapter on the basis of the 
Health Interview Survey 
policy of listing it among 
acute conditions. In addition, 
although the condition 
develops over a long period 
of time, it goes through acute 
phases, which is probably 
when most of the deaths at- 
tributed to it occur. A third 
reason for including it in this 
chapter is the reversible 
characteristic of the condition, 
which is not typical of most 
chronic conditions (although 
there is a nonreversible 
stage) (19). 

Several noteworthy 
features of the mortality trend 
from cirrhosis of the liver may 
be observed in Table 10. 
First, the death rate in the 
total population from this 
cause has increased steadily 
from 1950 to 1973, an 
average of approximately 60 
percent of whites and 242 
percent of nonwhites. The in- 
creases were greater for 
males than females (the 
male-to-female ratio was 1.18 
for whites and 1 .28 for non- 
whites). The nonwhite-to-white 
ratio inverted from 0.86 to 
1.82 during the 30-year 
period. 

In the 7 years following 
1973, there was a steady 
decrease of approximately 20 
percent in cirrhotic death 
rates. The trend after 1980 is 
not easy to discern, since it 
appears that the 1980 and 



93 



1979 rates are roughly iden- 
tical. Intercensal population 
overestimates may have 
caused a slight bloating of 
the mortality rates, and these 
misestimates would have in- 
creased through 1979. If that 
were the case, that artifact 
would have obscured the fact 
that the 1 980 data reflect a 
continuation of the downward 
trend. 

Whether or not there has 
been a continuation of the 
trend, the possible cause of 
the downward trend following 
1973 is still of some concern. 
John Baudhuin, who is the 
director of an alcohol and 
drug rehabilitation center, 
and who has been in the 
field for 12 years at various 
noted rehabilitation centers, 
cites five possible reasons for 
this decrease in death rates: 

(a) It was in the early 1970's 
that insurance companies 
started to cover inpatient 
services for alcoholism 
beyond detoxification. Inpa- 
tient stays got longer and 
more intensive, and extensive 
health care services were ex- 
tended to alcoholic inpatients. 

(b) Some of the very strict 
programs directed at drunk 
drivers were initiated at that 
time. These programs usually 
included a rehabilitation re- 
guirement for retaining a 
driver's license and/or 
avoiding a jail sentence. 

(c) Physicians started to 
receive better training in 
medical schools on how to 
treat alcoholics. Many physi- 
cians adopted a policy of be- 
ing unwilling to treat 
alcoholics for any of their 
medical problems unless they 
entered rehabilitation, and 
learned where to refer their 
patients for rehabilitation. 

(d) Participation in Alcoholics 
Anonymous became more 
socially acceptable. Many 



notables, including political 
figures (e.g., the President's 
wife, Betty Ford), sports 
figures, and movie stars 
publicized the fact that they 
were alcoholics and made 
televised public service an- 
nouncements asking 
alcoholics to seek help, 
(e) Generally, the health 
community adopted a new 
therapeutic model. The 
model was holistic and re- 
guired a regimen that includ- 
ed psychotherapy as well as 
medical treatments (20). 

We cannot, of course, 
conclude that these were the 
only factors operating 
throughout the 1970's that 
caused the decrement, but 
there is at least some 
evidence that they did have 
an impact. Of particular in- 
terest is the suggestion that 
changes in insurance 
coverage affected a death 
rate. Perhaps such 
coverages need to be re- 
viewed annually in search of 
other ways that they could 
favorably affect the health of 
the Nation. 

There has been some in- 
dication that the rise in 
alcohol use by adolescents 
has stopped or slowed, and 
there have been some na- 
tionally based grass roots 
campaigns initiated against 
drunken drivers, both of 
which could continue to af- 
fect these death rates in the 
future. 

American Indians also ex- 
perience excessive death 
rates from cirrhosis of the 
liver, as well as from 
pneumonia and influenza. In 
Table 11, age-adjusted 1971 
and 1979 death rates from 
leading causes are compared 
for Indians and Alaskan 
Natives. Those rates are also 
compared with those for 
other segments of the U.S. 
population. 

Over the 8-year period 
from 1971 to 1979, the 



American (American Indian 
and Alaskan Natives in 24 
reservation States as reported 
by the Indian Health Service) 
death rate from all causes 
decreased by 17.7 percent. 
During the same period, the 
total U.S. population death 
rate from all causes de- 
creased by 19.4 percent, 
causing the differential bet- 
ween these two groups to 
rise from 28 percent to 31 
percent. During the same 
period, American Indian 
death rates from cirrhosis of 
the liver decreased 18.9 per- 
cent while the whole popula- 
tion experienced a drop of 
only 14.1 percent, lowering 
the differential associated 
with that cause of death from 
4.70 to 4.44. American In- 
dians also experienced a 
tremendous decrease of 44.5 
percent in their death rate 
from influenza and 
pneumonia, but the total U.S. 
population experienced an 
even greater decrease of 
53.7 percent, raising the dif- 
ferential between the two 
groups from 1.69 to 2.03. 

Although American Indian 
deaths from cirrhosis of the 
liver are decreasing at a fast 
rate, and the rate of 
decrease is faster than it is 
for the general population, 
the Amerind death rate is so 
much higher than the general 
population rate that it will 
take a very long time for the 
differential to disappear 
without a programmatic effort 
to accelerate the rate of 
decrease. 

Although not all persons 
with cirrhosis are alcoholics, 
alcohol consumption is an 
established contributory fac- 
tor in the development of this 
disease. The results of 
surveys show that propor- 
tionately more people at 
lower socioeconomic levels, 
and that moderate and 
heavier drinking increases as 
social class rises (19, p. 17). 



The higher incidence of cir- 
rhosis among disadvantaged 
groups does not seem to be 
explained by higher rates of 
heavy drinking. It seems like- 
ly that, among disadvantaged 
persons who are heavy 
drinkers, nutritional deficien- 
cies may put them at a 
greater risk of developing cir- 
rhosis than the less disadvan- 
taged who are heavy 
drinkers. 

Although bronchitis is not 
one of the causes of death 
being discussed here, it is 
one of the major causes of 
American Indian deaths 
(though at a lesser rate for 
this group than for the rest of 
the U.S. population), and is 
on the rise for all groups 
listed in table 11. During the 
8-year period under discus- 
sion, the death rate rose 
more drastically for American 
Indians (31.8 percent) than it 
did for the population as a 
whole (24.2 percent), causing 
the differential to rise from . 
0.55 to 0.58. 



94 



Table 1 

Incidence of acute conditions and number of acute conditions per 1 00 persons per year, by age, sex, and condition group: United States, 



1981. 

(Data are based on household interviews of the civilian noninstitutionalized population. The survey design, general qualifications, 
and information on the reliability of the estimates are given in appendix I. Definitions of terms are given in appendix II) 







Under 






A C 
40 




Under 






A C 


Sex and Condition Group 


All 
All 


6 


6-16 


17-44 


Ysars 


All 


6 


6-16 


17-44 


i < ; 3 ' ' ■ 




Ages 


Years 


Years 


Years 


Cx UVcl 


Ages 


Years 


Years 


Years 


Cx UVcl 


Rnth Sexes 




Incidence of Acute Conditions 




Number of 


Acute Conditions 


per 






in Thousands 








100 Persons per year 


All Acute Conditions 


A ~7 O C\ A ~7 

478,047 


76,434 


1 06,9/9 


21 1 ,373 


83,262 


21 2.4 


380.0 


275.9 


217.6 


1 20.6 


Infective and Parasitic 






















Diseases 


53,185 


12,015 


14,744 


20,957 


5,469 


23.6 


59.7 


38.0 


21.6 


7.9 


Respiratory Conditions 


251,802 


40,078 


57,845 


108,051 


45,828 


111.9 


199.3 


149.2 


111.2 


66.4 


Upper Respiratory 






















Conditions 


125 399 


25,445 


30,948 


50,025 


18,981 


55.7 


126.5 


79.8 


51.5 


27.5 


Influenza 


111,847 


1 1,464 


24,492 


52,566 


23,326 


49.7 


57.0 


63.2 


54.1 


33.8 


Other Respiratory 






















Conditions 


I 4,000 


3,168 


2,406 


5,460 


"3 ^91 
o,OdL I 


6.5 


15.8 


6.2 


5.6 


c, 1 

o . I 


uigesnve oysiem Lyonaiuons . . 


91 771 


2,039 


5,945 


10,262 


O. ROP, 


9.7 


10.1 


15.3 


10.6 


R 1 

J. I 


injuries 


7 a fifin 


7,379 


15,629 


36,898 


1 A R7 A 
I 4, J / 4 


33.2 


36.7 


40.3 


38.0 


91 A 
c. I .4 


All Othor An ites 

Mil \J{t lei MUUlti 






















Conditions 




14,992 


12,817 


35,205 


1 O. fiP, 1 ^ 
1 0,003 


34.1 


14.2 


33.1 


36.2 


1 A R 

1 4.o 


Male 






















All Acute Conditions 


21 9,525 


40,599 


55,033 


90,41 1 


33,482 


202.2 


396.9 


277.4 


190.8 


1 07.6 


Infective and Parasitic 






















Diseases 


23,287 


5,758 


7,453 


8,277 


1,798 


21.4 


56.3 


37.6 


17.5 


5.8 


Respiratory Conditions 


115,710 


20,955 


29,239 


46,546 


18,968 


106.6 


204.9 


147.4 


98.2 


61.0 


Upper Respiratory 






















Conditions 


57 985 


13,803 


14,805 


21,825 


7,552 


53.4 


135.0 


74.6 


46.1 


24.3 


Influenza 


51,923 


5,795 


13,213 


22,766 


10,149 


47.8 


56.7 


66.6 


48.0 


32.6 


Other Respiratory 






















uonanions 


o,oud 


1,357 


1,221 


1,957 


1 9K7 


5.3 


13.3 


6.2 


4.1 


A 1 


uigesuve oysiem uonaitioris 


1 n kqi 
. . i u,oy i 


1,502 


3,202 


4,574 


I ,4 IO 


9.8 


14.7 


16.1 


9.7 


A R 
4.0 


injuries 


A O 9fifi 


4,190 


9,392 


22,337 


R OA 7 


38.9 


41.0 


47.3 


47.1 


on A 


All Plthpr An itp 






















Conditions 


07 r;7i 


8,193 


5,747 


8,675 


A Qcrc; 

4,yoo 


25.4 


80.1 


29.0 


18.3 


-ICQ 

i o.y 


Female 






















All Acute Conditions 


o c o coo 

258,522 


35,835 


51,946 


120,962 


49,779 


221.9 


362.5 


274.5 


243.1 


131 .3 


Infective and Parasitic 






















Diseases 


29,899 


6,257 


7,291 


12,681 


3,671 


25.7 


63.3 


38.5 


25.5 


9.7 


Respiratory Conditions 


136,092 


19,122 


28,606 


61,503 


26,661 


116.8 


193.4 


151.1 


123.6 


70.9 


Upper Respiratory 






















Conditions 


67,414 


1 1 ,642 


16,143 


28,200 


11,430 


57.9 


117.8 


85.3 


56.7 


30.1 


Influenza 


59,924 


5,669 


11,276 


29,800 


13,177 


51.4 


57.3 


59.6 


59.9 


34.8 


Other Respiratory 






















Conditions 


8,754 


1,811 


1,185 


3,503 


2,254 


7.5 


18.3 


6.3 


7.0 


5.9 


Digestive System 






















Conditions 


11,080 


536 


2,743 


5,688 


2,112 


9.5 


5.4 


14.5 


11.4 


5.6 


Injuries 


32,394 


3,190 


6,237 


14,561 


8,406 


27.8 


32.3 


33.0 


29.3 


22.2 


All Other Acute 






















Conditions 


. . 49,059 


6,729 


7,070 


26,530 


8,729 


42.1 


68 I 


37.4 


53 3 


23.0 



Note: Excluded from these statistics are all conditions involving neither restricted activity nor medical attention. 
Source: National Center for Health Statistics, B. Bloom: Current estimates from the National Health Interview Survey, United States, 
1981. Vital and Health Statistics. Series 10— No. 141. DHHS Pub. No (PHS) 83-1569. Public Health Service. Washington, DC. 
U S Government Printing Office. October 1982. Table 2, p 12. 



95 



Table 2 

Incidence of acute conditions, associated disability days, and persons injured, by race: United States. 1978. 

Race 

Item All 

races 1 White Black White Black 

Unadjusted rate Age-adjusted rate 2 



Acute Conditions 



Number of acute conditions per 100 persons per year 



All acute conditions 218.2 

Infective and parasitic diseases 24.1 

Respiratory conditions 116.5 

Upper respiratory conditions 60.8 

Influenza 49.0 

Other respiratory conditions 6.6 

Digestive system conditions 9.9 

Injuries 34.4 

All other acute conditions 33.3 

Days of disability associated with acute conditions 

Restricted-activity days 989.4 

Bed-disability days 444.4 

Work-loss days (ages 17 years and over) 3 376.6 

School-loss days (ages 6-16 years) 480.7 

Class of accident 

All classes of accident 31.6 

Moving motor vehicle 2.1 

While at work 4.9 

Home 11.9 

Other 13.9 



221.7 


199.6 


223.9 


25.2 


18.0 


25.6 


119.4 


98.8 


120.8 


60.5 


63.9 


61.4 


52.1 


29.7 


52.5 


6.8 


5.2 


6.9 


9.4 


13.3 


9.4 


35.2 


30.8 


35.4 


33.2 


33.5 


33.5 



Days of disability per 100 persons per year 



990.2 
432.8 
366.7 
484.3 



1,005.3 
543.2 
482.5 
478.4 



989.7 
433.3 
366.8 
NA 



Number of persons injured per 100 persons per year 



32.6 

2.0 
5.4 
12.3 
14.3 



27.2 

3.2 
2.0 
9.4 
12.9 



32.7 

2.0 
5.4 
12.4 
14.4 



191.0 

16.5 
92.8 
59.0 
29.2 
4.5 
13.3 
31.4 
33.0 



1,027.1 
551.3 
480.6 
NA 4 



26.9 

3.5 
2.2 
9.2 
12.5 



'Includes all other races. 

2 Ad|usted by the direct method to the age distribution of the civilian noninstitutionalized population or that of the currently employed 
population 

3 For currently employed population. 
4 Not applicable. 

Source National Center for Health Statistics. Division of Health Interview Statistics, 1 978 Health Interview Survey, unpublished data. 
Taken from National Center for Health Statistics, Health Data on Blacks in America, Rice, D P., Paper presented at Atlanta Univer- 
sity Center, November 19, 1979. Table 2. 



96 



Table 3 

Percent 1 of visits to office-based physicians and ratios for selected acute conditions, by race, 
1973 and 1979. 



Condition 



White 



1973 
All Other 



1979 Ratios 2 
White All Other 1973 1979 



Infective and Parasitic 

Diseases of the Respiratory System* 

Influenza 

Skin and Subcutaneous Tissue 



3.9 
15.0 
.7 
5.3 



4.2 
15.9 
1.8 
5.1 



3.5 
13.1 
n.a. 3 

5.3 



3.5 
14.0 



n.a. 



4.4 



91 
.90 
2.16 
.81 



n.a. 



.55 



.66 
.70 



'Entries are percents of all visits in the given year for each racial group. Columns would total to 100 percent if all conditions were 
listed in the table. 

2 The ratio (nonwhite to white) of number of visits per 1 ,000 population. 
3 n.a — not available. 

"This category includes some chronic respiratory diseases. 

Source: Compiled and abstracted by CHESS from 1) National Center for Health Statistics, J. DeLozier and R. Gagnon: The National 
Ambulatory Medical Care Survey: 1973 Summary. Vital and Health Statistics. Series 13, Number 21 DHEWPub. No (HRA) 76-1772. 
Public Health Service Washington, DC U.S. Government Printing Office, October 1975 Table 17. pp. 27-28. 2) National Center 
for Health Statistics: R. Gagnon, J. DeLozier, and T. McLemore: The National Ambulatory Medical Care Survey, United States, 
1979 Summary. Vital and Health Statistics. Series 13, No 66 DHHS Pub. No. (PHS) 82-1727 Public Health Service Washington, 
DC U.S. Government Printing Office, September 1982 Table 2, p. 20 



97 



Table 4 

Annual visit rate per 1,000 persons by age, sex, and race of patient, and principal diagnoses: United States, 1979. 



Age 



Sex 



Race 



Principal diagnosis 


All 


Under 


15-24 


25-44 


45-64 


65 years 








Black and 


and ICD-9-CM code 1 patients 


15 years 


years 


years 


years 


and over 


Female 


Male 


White 


all other 










Rate per 1,000 population 2 








1. Streptococcal sore throat and 






















scarlet fever 034 


10 


29 


-| -| 


*4 


*3 


— 


11 


1 n 


1 9 


9 


2. Viral warts 078.1 


15 


1 5 


30 


15 


*7 


*4 


14 


1 6 


-| 7 


1 

I 


3. Mycoses 110-118 


18 


1 1 
i i 


99 


26 


20 


'5 


23 


1 ft 

I O 


1 Q 


1 K 


4. Malignant neoplasm 






















of skin 172-173 


9 






*5 


13 


45 


8 




1 1 




5. Malignant neoplasm 






















of female breast 3 1 74 


15 






*9 


43 


32 


15 




1 7 


*ft 


6. Diabetes mellitus 250 


42 


* ft 


* 9 


15 


96 


159 


42 


41 


41 
H I 


4ft 


7. Obesity 278.0 


39 


*fi 




68 


63 


*13 


63 


1 4 


41 
H I 


94 

£lH 


8. Neurotic and personality 






















disorders 300-301 


64 




4ft 


125 


73 


44 


79 


4ft 


fift 
DO 


ftR 


9. Glaucoma 365 


14 






*2 


26 


78 


16 


1 ft 

I o 


1 R 


*7 


10. Cataract 366 


16 


* 1 




*2 


15 


111 


21 


1 1 


1 ft 
I o 


*4 


1 1 . Disorders of refraction 






















and accommodation . . . .367 


40 


9R 


ftfi 


39 


58 


44 


47 


ft9 


4ft 

HO 


on 


12. Disorders of conjunctiva . . .372 


15 


1 Q 


1 Q 


14 


18 


17 


16 


1 4 
I H 


1 R 


1 9 


13. Otitis media . . .381.0-381.4 382 


67 


1 Q4 




25 


26 


35 


64 


P.Q 


71 

/ l 


ftfi 
oo 


14. Essential hypertension 401 


110 


*ft 

o 


u 


58 


236 


410 


129 


QO 

C/VJ 


1 no, 


11ft 

I I o 


15. Hypertensive heart 






















disease 402 


9 






*2 


17 


43 


11 


O 


Q 


*ft 
o 


16. Ischemic heart 






















disease 410-414 


43 






8 


78 


225 


35 


D I 


47 
H / 


1 fi 


17. Congestive heart failure . .428.0 


6 






— 


*7 


46 


7 




7 




18. Cerebrovascular 






















disease 430-438 


8 


* 1 




*1 


10 


55 


8 


q 


o 
o 


Q 
O 


19. Acute pharyngitis 462 


38 


7ft 


oo 


31 


13 


17 


43 


oo 


41 

H I 


91 


20. Acute tonsilitis 463 


25 




O I 


10 


*3 


*2 


28 


99 


9R 


OA 


21. Acute URI's 4 of multiple 






















or unspecified sites 465 


70 


1 35 




49 


47 


64 


79 


fin 


fift 




22. Chronic sinusitis 473 


15 


i i 


o 


24 


14 


*14 


18 


1 9 
I c. 


1 R 


1 9 


23. Allergic rhinitis 






















(hay fever) 477 


46 


O I 


Rft 

DO 


53 


41 


*12 


48 


AA 
tH 


^n 


1 7 
I / 


24. Bronchitis 466.0, 490, 491 


42 


45 


24 


38 


52 


61 


42 


42 


43 


39 


25. Asthma 493 


32 


58 


18 


25 


27 


26 


34 


29 


34 


16 


26. Chronic airway obstruction, 






















NEC 5 496 


9 






*2 


16 


51 


6 


13 


10 


7 


27. Diseases of the esophagus, 






















stomach, and 






















duodenum 530-537 


29 


*6 


22 


29 


48 


58 


32 


26 


31 


17 


28. Hernia of abdominal 






















cavity 550-553 


17 


10 


*5 


11 


29 


45 


12 


21 


17 


13 



98 



Age Sex Race 



Principal diagnosis 


All 


Under 


15-24 


25-44 


45-64 


65 years 








Black and 


and ICD-9-CM code 1 patients 


15 years 


year. 


/< ars 


years 


and over 


Female 


Male 


White 


all other 


29. Noninfectious enteritis 






















and colitis 555-558 


21 


Q -1 
31 


A 7 


A Q 

i y 


A Q 
1 8 


A Q 
I 8 


nc 
^ O 


A 1 


O 1 


-1 O 

1 o 


30. Cystitis 3 595 


27 


* 1 O 

\ Z 


Q A 

3 I 


Z I 


OO 

33 


a n 
4U 


o v 




r ) □ 

26 


o o 
22 


31 . Diseases of male 






















genital organs 6 600-608 


41 


1 o 


* -I Q 


OC 


1 A 


AAA 
I I I 




A 1 


4 I 


o/ 


32. Disorders of breast 






















(excluding neoplasms) 3 






















610-611 


31 


* A 

4 


* A A 
1 1 


b3 


A C 


* A O 

1 2 


O 1 

3 1 




34 


1 0 


33. Inflammatory disease of 






















female pelvic 






















organs 3 614-616 


55 


* "7 

/ 


QQ 

88 


a no 
1 1)3 


oo 
oo 


* H -1 
1 1 


55 




48 


Jo 


34. Menopausal and post- 






















menopausal disorders 3 . . .627 


27 






O A 

21 


yfo 


* A ~7 


0~7 




n o 

30 


H O 

1 2 


35. Infections of skin and sub- 






















cutaneous tissue . . . .680-686 


23 


OQ 

Zo 


O A 

Z\ 


OO 

23 


OH 

^ 1 


22 


o -i 


Zb 


O A 

Z4 


1 (j 


36. Contact dermatitis and 






















other eczema 692 


26 


on 
29 


23 


on 

2y 


o c 


O /I 

^4 


OO 

2o 


2 b 




1 o 


37. Acne 706.1 


24 


A O 
I Z 


QO 

oZ 


on 


1 


* o 

o 


OU 


1 / 




1 4 


38. Osteoarthrosis, excluding 






















the spine 715 


21 




* a 
1 


1 


41) 


1 uu 


OO 

2o 


■1 A 


o o 
22 


i O 


39. Arthropathy, unspecified. .716.9 


19 




z 


1 n 

I U 


QQ 

oy 


"7/1 




1 7 


1 Q 
1 O 


O Q 

^o 


40. Dorsopathies 720-724 


41 


* o 
3 


a cz 

1 b 


54 


"7 C 

/ O 


"7 O 

/ o 


43 


O C\ 

39 


43 


o o 

28 


41. Rheumatism, excluding 






















the back 725-729 


51 


* 1 

I 


O "7 


6b 


OA 

by 


oU 




4b 


C O 

b^ 


4b 


42. Congenital anomalies . .740-759 


12 


on 
oU 


* Q 
O 


Q 

o 


* 

D 


D 


1 O 


1 O 

l ^ 


1 A 
I 4 


c 
O 


43. Fracture of upper limb .810-819 


27 


O A 

34 


o o 


oo 
23 


oo 
22 


o o 

28 




ol 




1 1 


44. Sprains and strains of 






















joints and adjacent 






















muscles 840-848 


64 


A A 
1 1 


/y 


y / 


1Q. 

fo 


A O 

43 


b4 


bo 


bo 


b/ 


45. Open wound of head, neck, 






















and trunk 870-879 


12 


o o 

23 


1 O 


■7 

/ 


* o 

8 


*4 


y 


1 o 


H O 

1 2 


9 


46. Open wound of upper 






















limb 880-887 


16 


1 1 


24 


ZD 


15 


* A -A 
1 1 


1 0 


o o 

23 


i <~< 

1 8 


b 


47. Allergy, unspecified 995.3 


24 


3o 


Zo 


oo 
^3 


A 1 


* 1 n 


^4 


^3 


O 7 

Z / 


c 
D 


48. Need for prophylactic vac- 






















cination and other pro- 






















phylactic measures .V03-V07 


18 


3/ 


* o 
8 


o 
8 


H A 

1 4 


o ^ 
24 


1 8 


-1 o 

1 8 


A Q 
1 8 


A Q 
1 8 


49. Routine infant or child 






















health check V20.2 


65 


97P. 
Z I O 










fin 


/ 1 




4D 


50. Normal pregnancy 3 V22 


202 


"3 


483 


416 


*3 




202 




211 


148 


51. Contraceptive 






















management 3 V25 


21 




54 


42 






21 




20 


30 


52. Followup examination 






















(following surgery) V67.0 


27 


*5 


21 


36 


41 


31 


32 


21 


29 


14 


53. General medical 






















examination V70 


77 


69 


105 


87 


67 


44 


79 


75 


82 


49 



1 Based on the International Classification of Diseases, 9th Clinical Modification (ICD-9-CM) 

2 Rates are based on estimates of the civilian noninstitutionalized population of the United States, for July 1, 1979, furnished 

by the Bureau of the Census 

3 Based on the female population only 

4 Upper respiratory infections. 

5 NEC = Not elsewhere classified. 

6 Based on the male population only 

"Figure does not meet standards of reliability or precision. 

Source: National Center for Health Statistics, R. Gagnon, J. DeLozier, and T. McLemore. The National Ambulatory Medical 
Care Survey, United States, 1979 Summary. Vital and Health Statistics. Series 13, Number 66 DHHS Pub. No. (PHS) 
82-1727. Public Health Service. Washington, DC. U.S. Government Printing Office, September 1982. Table 21, p. 45. 



99 



Table 5 

Number of office visits for acute upper respiratory infections of multiple or unspecified sites (acute URI), number and percent of drug 
visits, number of drug mentions, drug mention rate, and drug intensity rate, by selected characteristics: United States, 1980. 



Selected characteristic 



Office visits 



All visits 



Drug visits 1 



Drug 
mentions 



Drug 
mention 
rate 2 



Drug 
intensity 
rate 3 



Sex 



Number in 
thousands 



Both sexes 16.969 4 

Female 9,112 

Male 7,857 

Age 

Under 15 years 7,677 

15-24 years 2,295 

25-44 years 3,594 

45-64 years 2,058 

65 years and over 1 ,345 

Race 

White 14,901 

Black 1,880 

Problem status 

New problem 11 ,405 

Old problem 5,564 

Major reason for visit 

Acute problem 15,706 

Chronic problem, routine 414 

Chronic problem, flare-up 594 

Non-illness care *255 



Number in 
thousands 

15,977 
8,634 
7,343 



7,152 
2,113 
3,463 
1,941 
1,309 



14,064 
1,735 



10,697 
5,280 



14,866 
*366 
554 
*192 



Percent 

94.2 
94.8 
93.5 



93.2 
92.1 
96.4 
94.3 
97.3 



94.4 
92.3 



93.8 
94.9 



94.7 
'88.5 

93.3 
'75.2 



Number in 
thousands 

32,311 
18,002 
14,309 



12,654 
4,264 
7,169 
5,222 
3,001 



28,597 
3,351 



21,207 
11,104 



29,926 
*694 
1,431 
259 



Rate per visit 



1.90 
1.98 
1.82 



1.65 
1.86 
1.99 
2.54 
2.23 



1.92 
1.78 



1.86 
2.00 



1.91 
'1.68 

2.41 
M.02 



2.02 
2.09 
1.95 



1.77 
2.02 
2.07 
2.69 
2.29 



2.03 
1.93 



1.98 
2.10 



2.01 
'1.90 

2.58 
k 1.35 



1 A visit in which one or more drugs were ordered or provided 
2 Drug mentions divided by number of visits 
3 Drug mentions divided by number of drug visits. 

includes races other than white and black not shown as separate categories 

Source National Center for Health Statistics, B K Cypress: Medication therapy in office visits for selected diagnoses: The 
National Ambulatory Medical Care Survey, United States, 1980 Vital and Health Statistics. Series 13, No 71 DHHS Pub No 
(PHS) 83-1732 Public Health Service Washington, DC U S Government Printing Office January 1983, Table 33, p 38, 
'Figure does not meet standards of reliability or precision (more than 30 percent relative standard error). 



100 



Table 6 

Number of office visits for suppurative and unspecified otitis media, number and percent of drug visits, number of drug mentions, 
drug mention rate, and drug intensity rate, by selected characteristics: United States, 1980. 



Selected characteristic 



Office visits 



All visits 



Drug visits 1 



Drug 
mentions 



Drug 
mention 
rate 2 



Drug 
intensity 
rate 3 



Sex 



Number in 
thousands 



Both sexes 11 ,748 4 

Female 5,562 

Male 6,185 

Age 

Under 3 years 5,032 

3-14 years 4,315 

15 years and over 2,402 

Race 

White 11,019 

Black 518 

Problem status 

New problem 5,797 

Old problem - 5,951 

Major reason for visit 

Acute problem 9,031 

Chronic problem, routine 951 

Chronic problem, flare-up 1,214 

Post surgery/post injury * 1 54 

Non-illness care *398 



Number in 
thousands 

10,067 
4,842 
5,225 



4,405 
3,597 
2,066 



9,511 
397 



5,430 
4,636 



8,126 
556 
1,064 
*19 
*302 



Percent 

85.7 
87.1 
84.5 



87.5 
83.4 
86.0 



86.3 
76.7 



93.7 
77.9 



90.0 
58.4 
87.7 
'12.2 
'75.8 



Number in 
thousands 

18,168 



9,299 



7,851 
6,316 
4,001 



17,005 
877 



10,218 
7,950 



15,144 
813 
1,731 
*19 
461 



Rate per visit 



1.55 
1.59 
1.50 



1.56 
1.46 
1.67 



1.54 
1.69 



1.76 
1.34 



1.68 
0.85 
1.43 
'0.12 
"1.16 



1.80 
1 83 
1.78 



1.78 
1.76 
1.94 



1.79 
2.21 



1.88 
1.71 



1.86 
1.46 
1.63 
'1.00 
1.53 



1 A visit in which one or more drugs were ordered or provided 
2 Drug mentions divided by number of visits. 
3 Drug mentions divided by number of drug visits. 

"Includes races other than white and black not shown as separate categories 

"Figure does not meet standards of reliability or precision (more than 30 percent relative standard error). 
Source: National Center for Health Statistics, B K. Cypress: Medication therapy in office visits for selected diagnoses. The 
National Ambulatory Medical Care Survey. United States, 1980 Vital and Health Statistics. Series 13, No. 71 DHHS Pub. No 
(PHS) 83-1732 Public Health Service. Washington, DC U. S Government Printing Office January 1983, Table 29, p 36 



101 



Table 7 

Reported new cases of otitis media and incidence rates for 
American Indians and Alaska Natives, calender years 1962-78. 



American Indian and 
Alaskan Natives 



Calendar 


Number of 


Rate per 


Yea i 


Cases 


100,000 


1978 


68,775 


1 1,099.2 


1977 


61 ,546 


10,451.7 


1976 


58,871 


10,957.0 


1975 


56,569 


10,784.1 


1974 


53,555 


10,958.2 


1 973 


58,036 


12,103.6 


1972 


57,781 


12,289.8 


1971 


49,478 


10,742.4 


1970 


44,008 


9,745.0 


1969 


39,351 


8,892.3 


1968 


36,470 


8,413.7 


1967 


30,211 


7,118.8 


1966 


28,224 


6,909.6 


1965 


22,614 


5,688.2 


1964 


22,290 


6,243.7 


1963 


18,397 


5,211.7 


1962 


13,382 


3,801.7 



Source: Compiled by CHESS from 1) U. S Department of Health, Education, and 
Welfare: Trajectory of Indian Health Care. Indian Health Service, Vital Events Branch, 
January 1 7, 1 977. 2) U.S. Department of Health, Education and Welfare: Indian Health 
Service, DHEW Pub. No. (HSA) 79-12040. 



Table 8 

Number and percent 1 of patients discharged from short-stay hospitals, by category of first-listed diagnosis of selected acute conditions 
and by race: United States, 1968 and 1979. 



1968 



1979 



Category of First-Listed Diagnosis 


White 




All Other 


White 




All Other 


and ICD Code 


No. 


% 


No. 


% 


No. 


% 


No. 


% 


Infective and Parasitic 


















1968 (000-136) 1979 (000-139) 


238 


1 1 


47 


1.6 


444 


1.6 


85 


1.9 


Respiratory (selected) 


















Acute Upper Respiratory (460-465) 


304 


1.4 


34 


1.2 


220 


.8 


39 


.9 


Pneumonia (480-465) 


535 


2.5 


86 


3.0 


573 


2.1 


102 


2.2 


Acute Bronchitis and Bronchiolitis (466) 


148 


.7 


13 


.4 


180 


.7 


27 


.6 


Digestive (selected) 


















Appendicitis (540-543) 


262 


1.2 


26 


.9 


220 


.8 


23 


.5 


Cholelithiasis (574) 


397 


1.8 


21 


.7 


357 


1.3 


38 


.8 


Diseases of the genito-urinary 


















system (580-629) 


2,059 


9.5 


274 


9.4 


2,650 


9.7 


426 


9.3 


Diseases of the skin and subcutaneous 


















tissue (680-709) 


299 


1.4 


48 


1.7 


448 


1.6 


83 


1.8 


All Diagnoses (Acute and Chronic) 


21,629 




2,907 




27,451 




4,572 





'Percents do not add to 100 because only selected diseases are included in table For example, 1.1 percent of all white 
discharges in 1968 had infective and parasitic diseases as first-listed diagnoses, 98.9 percent were for all other diagnoses, 
acute or chronic. 

Source: Compiled and abstracted by CHESS from 1) National Center for Health Statistics: Inpatient Utilization of Short-stay 
Hospitals by Diagnosis, U S 1968, Vital and Health Statistics, Series 13, No. 12, p. 36. 2) National Center for Health 
Statistics, B J Haupt: Utilization of Short-stay Hospitals: Annual Summary for the United States, 1979. Vital and Health 
Statistics. Series 13, No. 60, Table 14, pp. 37-38 



102 



Table 9 

Age-adjusted death rates for influenza and pneumonia, by race and sex: United States, selected years from 1950 to 1980. 







Total 






White 






All other 




Year 


Both 






Both 






Both 








sexes 


Male 


Female 


sexes 


Male 


Female 


sexes 


Male 


Female 










Rate per 100,000 population 








19501 


26.2 


30.6 


22.0 


22.9 


27.1 


18.9 


56.9 


63.4 


50.6 


1960 


28.0 


35.8 


21.8 


24.6 


31.0 


19.0 


55.2 


68.0 


43.3 


1970 


22.1 


28.8 


16.7 


19.8 


26.0 


15.0 


38.1 


50.1 


27.9 


1980 


12.9 


17.4 


9.8 


12.2 


16.2 


9.4 


18.0 


26.1 


11.9 


Decrease 1950-1980 


50.8 


43.1 


55.5 


46.7 


40.2 


50.3 


68.4 


58.8 


76.5 


% total* decrease occurring in 1970-1980 .... 


69.2 


86.4 


56.6 


71.0 


89.9 


58 9 


51.7 


64 


41 3 



'There was a substantial decrease in death rates between 1970 and 1980. This now contains the percentage of that decrease 

that occurred during the last of these three decades (i.e. 1970-1980: 1950-1980). 

1 Based on enumerated population adjusted for age bias in the population of races other than white. 

Source: Compiled by CHESS from 1) Department of Health, Education, and Welfare: "Mortality Trends for Leading Causes of Death, 
U.S. 1950-69." Rockville, MD Series 20, No. 16. Table K, p. 30. 2) Department of Health, Education, and Welfare: Monthly Vital 
Statistics Report, Summary Report, Final Mortality Statistics 1970, Vol. 22, No 8, 1980, Vol. 32, No 4. 



Table 10 

Age-adjusted death rates for cirrhosis of the liver, by race and sex: United States, selected years from 1950-1980. 



Total White All other 

Year Both Both Both 

sexes Male Female sexes Male Female sexes Male Female 

Rate per 100,000 population 

19501 8.5 11.4 5.8 8.6 11.6 5.8 7.4 9.0 5.9* 

1960 10.5 14.5 6.9 10.3 14.4 6.6 11.9 14.9 9.1 

1970 14.7 20.2 9.8 13.4 18.8 8.7 23.8 31.3 17.4 

1980 12.2 17.1 7.9 11.0 15.7 7.0 20.0 28.1 13.5 

% Increase 1950-1973 76.5 83.3 70.7 59.3 66.4 50.0 241.9 267.7 205.1 

% Decrease 1973-1980 18.7 18.2 20.2 19.7 18.6 19.5 20.9 17.1 25.0 

% Increase 1950-1980 43.5 50.0 36.2 27.9 35.3 20.7 170.3 212.2 128.8 



1 Based on enumerated population adjusted for age bias in the population of races other than white 

Note: Asterisk indicates age-adjusted rates where more than half of the age-specific rates are based on fewer than 20 deaths. 
Source: Compiled by CHESS from 1) Department of Health, Education, and Welfare "Mortality Trends for Leading Causes of 
Death, U.S. 1950-69." Rockville, MD. Series 20, No. 16. Table K, p. 30. 2) Department of Health, Education, and Welfare: 
Monthly Vital Statistics Report, Summary Report, Final Mortality Statistics 1970, Vol. 22, No. 8. 3) Department of Health and 
Human Services: Monthly Vital Statistics Report, Advance Report of Final Mortality Statistics, 1980, Vol. 32, No. 4. 



103 



Table 11 

Age-adjusted death rates (per 100,000 population) for American Indians and Alaska Natives in 24 reservation States, U.S. calendar 
years 1971 and 1979. 







Indian 








Ratio of 
I la. Li W {J \ 






Health 


U.S. 1 






IHS to 




Year 


Service 


Total 


White 


All Other 


U.S. 


All Causes 


1971 


935.5 


730.9 


694.4 


1,046.2 


1.28 


1979 


770.2 


588.8 


563.4 


776.3 


1.31 


Major cardiovascular diseases 


1971 
1979 


251.1 
219.1 


352.0 
259.3 


341 .4 
252.6 


457.9 
313.6 


0.71 
0.84 


Accidents 


1971 


183.0 


55.3 


52.6 


75.5 


3.31 


1979 


140.7 


43.7 


42.9 


50.5 


3.22 


Malignant Neoplasms 


1971 
1979 


84.4 
78.9 


129.7 
133.2 


126.8 
130.2 


158.6 
159.0 


.65 
.59 


Cirrhosis of Liver 


1971 
1979 


66.8 
54.2 


14.2 
12.2 


12.9 
1 1.1 


24.0 
20.1 


4.70 
4.44 


Influenza and Pneumonia 


1971 
1979 


41.6 
23.1 


24.6 
11.4 


22.3 
10.7 


41.9 
16.1 


1.69 
2.03 


Diabetes Mellitus 


1971 
1979 


31.7 
22.8 


14.5 
10.0 


13.2 
9.0 


27.7 
18.5 


2.19 
2.28 


Tuberculosis, all forms 


1971 
1979 


10.6 
4.4 


2.3 
0.7 


2.8 
0.4 


8.0 
2.5 


4.61 
6.29 


Bronchitis 


1971 
1979 


6.6 
8.7 


12.0 
14.9 


12.0 
15.3 


10.0 
10.7 


0.55 
0.58 



1 1969 rates (latest available). 

Source: Compiled and abstracted by CHESS from 1) Department of Health, Education, and Welfare "Indian Health Trends 
and Services," 1974 Edition Public Health Service, Table 42, p 33 2) Department of Health and Human Services: FY 7984 
Budget Appropriation, Indian Health Service, "Chart Series" Tables. Office of Program Statistics, Division of Resource Coor- 
dination. Indian Health Service April, 1983 3) Department of Health and Human Services: Monthly Vital Statistics Report, 
DHHS Pub. No. (PHS) 82-1120, Vol 31, No 6 



104 



References 

1 . National Center for Health 
Statistics: Acute conditions in- 
cidence and associated 
disability, United States, July 
1974-June 1975. Vital and 
Health Statistics, Series 10, 
No 114. DHEW Pub. No. 
(HRA) 77-1541, U.S. Govern- 
ment Printing Office, 
Washington, DC, February 
1977. 

2. Black, E.R.: "Acute condi- 
tions incidence and 
associated disability, United 
States, July 1976-June 
1977." Vital and Health 
Statistics Series 10, Number 
125. DHEW Pub. No. (PHS) 
78-1553. Public Health Serv- 
ice. U.S. Government Printing 
Office, September, Hyattsville, 
MD, 1978. 

3. Bloom B.: "Current 
Estimates from the National 
Health Interview Survey: 
United States, 1981." Vital 
and Health Statistic, Series 
10, No. 141. DHHS Pub. No. 
(PHS) 83-1569. Public Health 
Service. U.S. Government 
Printing Office. Washington, 
DC, October 1982. 

4. National Center for Health 
Statistics, Rice, D.P., Director: 
Health Data on Blacks in 
America. Presentation at the 
Atlanta University Center, 
November 19, 1979. 

5. Aday, L. and Andersen, 
R.: Access to Medical Care. 
Health Administration Press, 
Ann Arbor, Ml, 1975. 

6. Danchik, K.M.: "Physician 
visits, volume and interval 
since last visit, United States, 
1971." Vital and Health 
Statistics, Series 10, No. 97. 
DHEW Pub. No. (HRA) 
75-1524. Public Health Serv- 
ice. U.S. Government Printing 
Office, Rockville, MD, March 
1975. 

7. Collins, J.G.: "Physician 
visits, volume and interval 
since last visit, United States, 



1980." Vital and Health 
Statistics. Series 10, No. 144. 
DHHS Pub. No. (PHS) 
83-1572. Public Health Serv- 
ice. U.S. Government Printing 
Office, Washington, DC, June 
1983. 

8. Gentile, A.: "Physician 
visit, volume and interval 
since last visit. United States, 
1975." Vital and Health 
Statistics, Series 10, Number 
128. DHEW Pub. No. (PHS) 
79-1556. Public Health Serv- 
ice. U.S. Government Printing 
Office, Washington, DC, April 
1979. 

9. Gray, R.H. and Silkey, B.: 
"Pelvic Inflammatory Disease: 
Causes and Consequences" 
In The Changing Risk of 
Disease in Women: An 
Epidemiological Approach 
edited by Gold, E.B., The 
Collamore Press, Lexington, 
1981. 

10. Gagnon, R., DeLozier, 
J., and McLemore, T.: "The 
National Ambulatory Medical 
Care Survey, United States 
1979 Summary." Vital and 
Health Statistics, Series 13, 
Number 66. 

1 1 . DeLozier, J.E., and 
Gagnon, R.O.: "The National 
Ambulatory Medical Care 
Survey: 1973 Summary, 
United States, May 1 973-April 
1974." Vital and Health 
Statistics, Series 13, Number 
21. DHEW Pub. No. (HRA) 
76-1772. Public Health Serv- 
ice. U.S. Government Printing 
Office, Washington, DC, 
October 1975. 

12. Cypress, B.K.: Medica- 
tion therapy in office visits for 
selected diagnoses: The Na- 
tional Ambulatory Medical 
Care Survey, United States, 
1980. Vital and Health 
Statistics, Series 13, Number 
71. DHHS Pub. No. (PHS) 
83-1732. Public Health Serv- 
ice. U.S. Government Printing 
Office, Washington, DC, 
January 1983. 



13. Axelsson, A.; and Lewis 
O: "Aspects of delivery of 
ear, nose, and throat care to 
Montana Indians." Public 
Health Report 89:551-557, 
November-December 1974. 

14. Johnson, E.A., Exendine, 
J.N.: Illness Among Indians 
and Alaska Natives 
1970-1978 DHEW Pub. No. 
(HSA) 79-12040. Indian 
Health Service. Public Health 
Service. U.S. Government 
Printing Office, Washington, 
DC, 1979. 

15. National Institutes of 
Health: "The Health of 
America's Nonwhite, popula- 
tion status report and future 
plans for dealing with disease 
more prevalent or severe in 
Nonwhite." Department of 
Health, Education, and 
Welfare. Washington, DC, 
November 11, 1971 (un- 
published document). 

16. Social Security Ad- 
ministration: "Standards for 
good medical care." DHEW 
Pub. No. (SSA) 75-11926. 
U.S. Government Printing Of- 
fice, Washington, DC, 
February 1975. 

17. Burton, L.E., Smith, H.H., 
and Nichols, A.W.: Public 
Health and Community 
Medicine, third edition. 
Williams and Wilkins, 
Baltimore/London, 1980. 

18. Haupt, B.J.: "Utilization 
of Short Stay Hospitals: An- 
nual summary for the United 
States, 1979." Vital and 
Health Statistics, Series 13, 
Number 60. DHHS Pub. No. 
(PHS) 82-1721. Public Health 
Service. U.S. Government 
Printing Office, Washington, 
DC, December 1981. 

19. National Institute on 
Alcohol Abuse and 
Alcoholism: Alcohol and 
health, new knowledge. 
Preprint edition. Alcohol, 



Drug Abuse, and Mental 
Health Administration. U.S. 
Government Printing Office, 
Washington, DC, June 1974. 
20. Telephone conversation: 
Baudhuin, J., Director. St. 
John's Treatment Center 
(alcohol and drug rehabilita- 
tion), 3530 Fleming Avenue, 
Pittsburgh, PA, May 10, 
1984. 



105 



List of Tables 

1. Incidence of acute condi- 
tions and number of acute 
conditions per 100 persons 
per year, by age, sex and 
condition group: United 
States, 1981. 

2. Incidence of acute condi- 
tions, associated disability 
days, and persons injured, 
by race: United States, 1978. 

3. Percent of visits to office- 
based physicians and ratios 
for selected acute conditions, 
by race, 1973 and 1979. 

4. Annual visit rate per 1,000 
persons by age, sex, and 
race of patient, and principal 
diagnoses: United States, 
1979. 

5. Number of office visits for 
acute upper respiratory infec- 
tions of multiple or 
unspecified sites (acute URI), 
number and percent of drug 
visits, number of drug men- 
tions, drug mention rate, and 
drug intensity rate, by 
selected characteristics: 
United States, 1980. 

6. Number of office visits for 
suppurative and unspecified 
otitis media, number and per- 
cent of drug visits, number of 
drug mentions, drug mention 
rate, and drug intensity rate, 
by selected characteristics: 
United States, 1980. 

7. Reported new cases of 
otitis media and incidence 
rates for American Indians 
and Alaska Natives, calendar 
years 1962-1978. 

8. Number and percent of 
patients discharged from 
short-stay hospitals, by 
category of first-listed 
diagnosis of selected acute 



conditions and by race: 
United States, 1968 and 
1979. 

9. Age-adjusted death rates 
for influenza and pneumonia, 
by race and sex: United 
States, selected years from 
1950 to 1980. 

10. Age-adjusted death rates 
for cirrhosis of the liver, by 
race and sex: United States, 
selected years from 1950 to 
1980. 

1 1 . Age-adjusted death rates 
(per 100,000 population) for 
American Indians and Alaska 
Natives in 24 reservation 
States, U.S. calendar years 
1971 and 1979. 



106 



Chapter V 



Chronic Disease 
Conditions 



Table of Contents 



Overview 109 

A. Introduction 109 

B. Major Cardiovascular Diseases 109 

1. Diseases of the Heart 110 

2. Cerebrovascular Disease 111 

3. Arteriosclerosis 111 

4. Hypertension 112 

5. Risk Factors of Major 
Cardiovascular Diseases 113 

C. Malignant Neoplasms— (Cancer) 113 

1. Incidence— All Sites 113 

2. Incidence— Selected Sites 113 

3. Mortality— All Sites 114 

4. Mortality— Selected Sites 115 

5. Risk Factors of Cancer 116 

D. Diabetes 117 

E. Chronic Respiratory Conditions 118 

F. Limitation of Activity due to Chronic Disease 
Conditions 120 

Tables 121 
References 1 33 
List of Tables 134 
List of Figures 135 



108 



Chapter V Chronic Disease 

Condition 



Overview 

Racial differentials of health 
status indicators remain high 
with respect to leading 
chronic disease conditions. 
Major cardiovascular 
diseases not only accounted 
for 50 percent of all deaths in 
1 980 but also were responsi- 
ble for more disability and 
economic loss than any other 
group of diseases. While the 
disadvantaged fare worse 
than the remainder of the 
population with regard to car- 
diovascular disease, racial 
differentials are decreasing. 
Nonwhites in comparison 
with whites experienced a 
slightly greater decrease in 
age-adjusted death rates 
from heart disease in the 
past 10 years. The same 
directional change was 
observed for cerebrovascular 
disease (stroke), for which 
nonwhites had an age- 
adjusted death rate higher 
than whites in 1980, but ex- 
perienced a greater decrease 
in this death rate between 
1970 and 1980, producing a 
smaller racial differential. 
Blacks continue to have a 
higher prevalence rate of 
elevated blood pressure, 
which increases their risk of 
heart attack and stroke, but a 
larger percentage of blacks 
are currently controlling this 
condition with medication 
than was true in the past. 

Cancer mortality among 
whites increased only 
minimally during the past 10 
years (1.4 percent), but the 
rate among nonwhites in- 
creased substantially (6.7 
percent). With regard to this 
disease, the racial gap in 
health status is broadening. 
While nonwhites had lower 
death rates from cancer of 



the respiratory system in 
comparison to whites, they 
have experienced a greater 
increase in death rates from 
this cause than have whites 
in the past 10 years. Non- 
white males had a higher 
death rate than did white 
males from cancer of the 
genital organs (mostly pros- 
tate cancer), but an only 
slightly greater increase in 
this death rate during the 
past 10 years. White females 
had higher death rates than 
nonwhite females from breast 
cancer in 1980 and in 1970. 
Nonwhite females had higher 
death rates from cancer of 
the genital organs than white 
females, both in 1980 and in 
1970. Another racial/ethnic 
minority, Hispanics, ex- 
perienced lower incidence 
rates for almost all sites of 
cancer in comparison with 
whites. 

Nonwhites have had twice 
the age-adjusted death rate 
from diabetes as have whites, 
and the racial differential in- 
creased slightly from 1.95 in 
1970 to 2.06 in 1980. Again, 
the racial gap in health status 
from this source is 
broadening. 

Nonwhites have substan- 
tially higher incidence of and 
mortality from tuberculosis in 
comparison with whites, with 
Indian and Alaska Natives 
faring worse than all non- 
whites combined. With 
respect to both morbidity and 
mortality, however, the "In- 
dian and Alaska Native/All 
Races" ratio decreased dur- 
ing 1969-1979, while the 
"Nonwhite/AII Races" ratio 
remained relatively static for 
the same period. 

With regard to limitation of 
activity due to all chronic 
disease conditions, the poor 
are over two and one-third 
times as likely to have activity 



limitation as the nonpoor. 

In summary, the differen- 
tial health status of racial 
minorities with regard to ma- 
jor cardiovascular disease, 
cancer, diabetes, and tuber- 
culosis is striking. While im- 
provements in their relative 
standing was observed with 
regard to major car- 
diovascular disease and 
tuberculosis for Indian and 
Alaska Natives, such im- 
provements were not noted 
for other nonwhite racial 
groups. The converse has 
been true with regard to 
cancer and diabetes. 

A. introduction 

Chronic disease conditions 
are leading causes of both 
morbidity and mortality in the 
United States today. Not only 
have the three leading 
causes of death for the past 
several years been due to 
chronic diseases, but an 
estimated 14.4 percent of the 
population of the 1981 
National Health Interview 
Survey reported a limitation 
of activity due to chronic 
conditions (1 , p. 3). 

Available morbidity and 
mortality data will be used in 
this chapter to describe the 
impact of chronic disease 
conditions on the disadvan- 
taged compared with the 
population as a whole. Mor- 
bidity data were obtained 
from the National Cancer In- 
stitute's Surveillance, 
Epidemiology, and End 
Results (SEER) Program and 
from the following surveys of 
the National Center for Health 
Statistics (NCHS): (a) the Na- 
tional Health Interview 
Survey, (b) the National 
Health and Nutrition Ex- 
amination Survey, (c) the Na- 
tional Hospital Discharge 
Survey, and (d) the National 



Ambulatory Medical Care 
Survey. Mortality data were 
obtained from the vital 
statistics program of the Na- 
tional Center for Health 
Statistics and from SEER, 

This chapter discusses the 
chronic diseases that are 
leading causes of death. The 
discussion of these diseases 
revolves around available 
mortality data and, when 
possible, morbidity data. The 
National Center for Health 
Statistics publishes 
prevalence rates for all 
chronic diseases combined, 
reported in this chapter in 
Section F. For the purposes 
of the National Health Inter- 
view Survey, from which 
chronic disease prevalence 
rates are derived, a condition 
is considered chronic if 1) the 
condition is described by the 
respondent as having been 
first noticed more than 3 
months before the week of 
the interview; or 2) it is 
among those conditions listed 
by NCHS which are always 
considered chronic 
regardless of the date of 
onset (1 , p. 49). 

Additional caveats on the 
interpretation of the data 
presented are contained in 
Chapter I of this book. 

B. Major Cardiovascular 
Diseases 

The disease category "major 
cardiovascular disease" com- 
prises all diseases of the 
heart and blood vessels. It in- 
cludes 1) diseases of the 
heart; 2) hypertension; 3) 
cerebrovascular diseases (in- 
cluding stroke); 4) 
arteriosclerosis; and 5) other 
diseases of the arteries. 

Cardiovascular diseases 
are the major diseases in the 



109 



United States today, having 
been the cause of almost half 
of all deaths that occurred in 
1980 (2). "The arteriosclerotic 
diseases, particularly cor- 
onary heart disease and 
cerebrovascular disease 
(stroke), cause more deaths, 
disability, and economic loss 
in the United States than any 
other group of acute or 
chronic diseases." (3, p. 1) 

Heart disease and stroke, 
when ranked with other 
diseases, are the first and 
third leading causes of death, 
while hypertension and 
atherosclerosis are not only 
responsible for deaths direct- 
ly but increase the risk of 
both heart disease and stroke 
(see Table 1). 

Cardiovascular disease 
became the leading cause of 
death in 1930. Since 1950, 
however, there has been a 
34 percent decrease in the 
age-adjusted death rate from 
that cause, with 20 percent 
of the decline occurring dur- 
ing the 10 years from 1970 
to 1980. While cardiovascular 
disease deaths still make up 
about 50 percent of all 
deaths, the decline has been 
so precipitous, particularly in 
the last 10 years, that the Na- 
tional Heart, Lung, and Blood 
Institute (NHLBI) organized a 
conference in 1978 to ex- 
amine the causes of this 
phenomenon (4). The practic- 
ing cardiologists, biometri- 
cians, and epidemiologists 
attending the conference 
concluded that the observed 
decline in deaths was real 
and was not a function of 
any changes in the Interna- 
tional Classification of 
Diseases (ICD) or of any ar- 
tifact with regard to age ad- 
justment. While no one treat- 
ment modality is considered 
responsible for the recent 
decline in cardiovascular 



disease mortality, the decline 
is believed to be attributable 
to changes in the concept of 
coronary care, new drugs, 
and new surgical and 
diagnostic techniques. Also, 
reductions in cigarette smok- 
ing, hypertension, and 
cholesterol intake are thought 
to have played a part. "One 
can conclude that primary 
prevention and improved 
medical treatment each have 
clearly played a role, but how 
much credit each should 
receive is unclear." (4, p. 66) 

The observed decline in 
death rates due to car- 
diovascular disease not- 
withstanding, morbidity and 
mortality resulting from car- 
diovascular disease is still 
substantial. In the following 
sections, each of the 
diseases making up the ma- 
jor cardiovascular disease 
group will be discussed in 
terms of the relative impact 
on the disadvantaged com- 
pared with the remainder of 
the population. 
1 . Diseases of the Heart 

Heart disease prevalence 
rates were higher among 
whites (51.7 per 1,000 per- 
sons) than among nonwhites 
(41.5 per 1,000) in 1972, 
when heart disease 
prevalence rates from the 
Health Interview Survey were 
last published (5). While more 
recent household interview 
data with racial breakdowns 
are not available, office- 
based physician care, drug 
use, hospital utilization, and 
mortality data will be used to 
measure the impact of this 
disease on the 
disadvantaged. 

In 1980, an estimated 
10.4 million visits to office- 
based physicians were made 
for ischemic heart disease 
conditions. Of these, 96 per- 
cent (almost 10 million) con- 
sisted of visits by white pa- 
tients and 4 percent (over 0.4 
million) of visits by black pa- 



tients (6). These percentages 
are incongruent with the 
population distribution by 
race: whites make up about 
83 percent of the population, 
blacks represent 12 percent 
of the population, and other 
races about 5 percent. 

One cannot conclude from 
these data, however, that 
prevalence rates for non- 
whites are greater, since the 
data described office-based 
physician visits only. From 
our sources, it was not possi- 
ble to determine whether or 
not proportionately fewer 
physician visits were also 
made by blacks to outpatient 
departments or emergency 
rooms for ischemic heart 
disease. ". . .Respiratory 
disease and circulatory 
disease dominate the world 
of office-based ambulatory 
care. Their dominance ap- 
pears in the number of office 
visits in which they figure as 
a principal diagnosis; it also 
can be seen in most of the 
various measures of drug 
utilization associated with 
their treatment." (7, p. 5) 

1980 was the first year in 
the 8-year history of the Na- 
tional Ambulatory Medical 
Care Survey (NAMCS) in 
which respondents reported 
the number and names of 
specific drugs used (7). In 
Table 2 the distribution of 
drugs mentioned by selected 
therapeutic categories is 
presented by race. "A drug 
mention is the physician's 
entry of pharmaceutical agent 
ordered or provided— by any 
route of administration— for 
the purpose of prevention, 
diagnosis, or treatment." (7, 
p. 4) Drug intensity rate is 
the ratio of drug mentions to 
drug visits. "In its drug inten- 
sity rate, the circulatory 
disease category clearly 
outranks all others." (7, p. 5) 
As a percentage of all drug 
mentions, cardiac drugs 
represent a higher percent- 
age (3.98 percent) for whites 



than for blacks (3.12 percent) 
or for Hispanics (1.78 per- 
cent) (see Table 2). 

In addition to ambulatory 
care, heart conditions are 
responsible for a con- 
siderable amount of hospital 
utilization. Heart disease ac- 
counted for 3 1 /3 million 
discharges from short-stay 
hospitals in 1981 (see Table 
3). As a proportion of total 
discharges, 9.3 percent of all 
discharges of white patients 
and 5.2 percent of all 
discharges of nonwhite pa- 
tients were for heart condi- 
tions. In addition, the average 
length of hospital stay was 
longer for nonwhites (10.2 
days) than it was for whites 
(9.2 days). Thus, hospitaliza- 
tion for heart conditions 
represented a lower propor- 
tion of all discharges among 
nonwhites than among whites 
in 1981. Although this finding 
by itself is consistent with the 
hypothesis of lower 
prevalence rates for this 
disease among nonwhites, 
this is not the case when 
other measures of heart 
disease are examined. When 
we take into account the 
longer lengths of stay and 
the higher death rates ex- 
perienced by nonwhites, we 
obtain a profile that is more 
consistent with the hypothesis 
of higher prevalence rates for 
this disease among non- 
whites. Perhaps the 
discrepancy arises from the 
limited degrees of freedom 
that derive from using 
percentages as a measure. 

In Table 3, hospitalization 
data for all heart diseases 
combined are presented for 
1975 and 1981. However, 
changes in the ICD between 
1975 and 1981 make a com- 
parison of specific heart con- 
ditions over time difficult. 
Therefore, a shorter period, 
1979 to 1981, is employed in 
the calculations that follow. 



110 



The number of discharges for 
specific heart diseases (8, 9) 
was used to calculate 
percentage changes in 
hospitalization for whites and 
nonwhites between 1979 and 
1981. 



Disease 

Acute myocardial infarction 
Atherosclerotic heart disease 
Other ischemic heart disease 
Congestive heart failure 



As shown above, the in- 
crease in hospitalization for 
atherosclerotic heart disease 
and other ischemic heart 
disease was substantially 
higher for nonwhites than for 
whites, while the increase in 
hospitalization for acute 
myocardial infarction and 
congestive heart failure was 
similar for nonwhites and for 
whites during this time 
period. 

Having observed higher 
prevalence rates, physician 
visit rates, and hospital utiliza- 
tion rates among whites com- 
pared with nonwhites, we 
turn now to mortality rates 
(see Table 4) and observe 
that (a) the rates have drop- 
ped precipitously for both 
racial categories, (b) the rate 
of drop has been greater 
among females than males, 

(c) the drop for "all other 
races" was slightly greater 
than the drop for whites, and 

(d) the rate differential be- 
tween the racial categories 
for females by 1980 was 
negligible and between males 
was only approximately 8 
percent. As explained below, 
however, this analysis con- 
tains an artifact of racial 
groupings, and blacks have 
not fared as well as the other 
races within the "all other 
races" category. 

Beginning in 1976, age- 
adjusted mortality rates have 
been presented in monthly 



vital statistics reports with 
more refined racial 
breakdowns. Race has been 
disaggregated by "white" 
and "all other races" with 
"all other races" being fur- 
ther disaggregated into 



All Other 
Whites Races 

22.0 18.5 
5.3 21.9 
28.2 44.7 
26.5 25.0 



"black" and "all other 
races." The age-adjusted 
mortality rate for diseases of 
the heart in 1980 per 
100,000 population was 
255.7 for blacks, 234.2 for 
nonwhites (including blacks), 
197.6 for whites, and 202.0 
for all races. The black-to- 
white ratio of heart disease 
mortality rates (1 .29) was 
higher than the nonwhite-to- 
white ratio (1.19). The dif- 
ferential was even greater 
when comparing rates for 
females: the ratio of heart 
disease mortality rates of 
black females to white 
females is 1.49. 

To summarize, whites 
have higher reported 
prevalence rates as well as 
higher office-based physician 
visit and hospital utilization 
rates for diseases of the 
heart, but lower mortality 
rates from this cause than 
nonwhites. On the other 
hand, while death rates have 
been on the decline for both 
race groups, the decrease 
has been larger for non- 
whites, producing a smaller 
racial differential in 1980 than 
in 1950. Thus, the racial gap 
has narrowed somewhat with 
regard to this condition, and 
a possible improvement has 
occurred in medical care 
among the disadvantaged 
vis-a-vis diseases of the 
heart. 

2. Cerebrovascular Disease 

"The term 'stroke' is ap- 
plied to the sudden onset of 



vascular disorders affecting 
the brain or spinal cord. The 
prototype clinical manifesta- 
tions are sudden weakness 
or paralysis of an arm or leg; 
disturbance of speech, 
balance, vision, or memory; 
or, even coma. There are 
three main causes of stroke: 
1) blockage of an artery by 
atherosclerosis; 2) hemor- 
rhage into the brain because 
of a rupture of an artery 
(usually associated with 
hypertension); and, 3) an em- 
bolus, often the result of a 
blood clot from the heart 
lodging in an artery." (3, 
p. 15) 

Cerebrovascular disease 
was responsible for about 
800,000 hospitalizations in 
1981, representing 2.2 per- 
cent of all discharges among 
whites and 1.6 percent 
among all other races (see 
Table 3). 

"Although the treatment of 
stroke has improved during 
recent years, a major stroke 
is about as likely to be lethal 
as an acute heart attack and 
is more likely to produce 
severe disability with conse- 
quent lost earning potential 
and severe socioeconomic 
impact." (3, p. 15) Of the 
roughly 250,000 Americans 
who survive strokes, "... 
many remain disabled by 
paralysis, speech difficulties, 
and memory loss. Nearly 10 
percent of nursing home ad- 
missions in people under 65 
are because of strokes." (10, 
p. 56) 

For the past several years 
cerebrovascular disease has 
been the third leading cause 
of death in the United States, 
accounting for 8.6 percent of 
all deaths in 1980 (see Table 
1). Age-adjusted death rates 
for cerebrovascular diseases 
decreased 54 percent be- 
tween 1950 and 1980 (see 
Table 5), an even greater 



decline than that observed 
for heart disease (34 percent) 
in the same time period. 
While a decrease in death 
rates from this cause occur- 
red in the total population, a 
slightly higher percentage 
decrease (41.2 percent) was 
experienced by all other 
races than was experienced 
by whites (38.5 percent) be- 
tween 1970 and 1980. Thus 
the ratio of nonwhite to white 
mortality rates was lower in 
1980 (1.66) than in 1970 
(1.73). The burden of this 
cause of death is still much 
heavier on racial minorities 
than the rest of the popula- 
tion, and heavier on blacks 
than on all nonwhites. Non- 
whites have a 66 percent 
higher death rate than whites, 
while black death rate 
(2, p. 32) runs 80 percent 
higher than the white death 
rate. 

Several risk factors are 
associated with cerebro- 
vascular disease, only the 
most prominent of which are 
mentioned here. Persons 
who have high blood 
pressure, diabetes, or certain 
ECG changes are at greater 
risk of developing a stroke 
(11, p. 338). As the following 
sections indicate, the disad- 
vantaged seem to have 
higher rates of several of the 
risk factors associated with 
stroke, especially hyperten- 
sion and diabetes. 
3. Arteriosclerosis 

Arteriosclerosis, a condi- 
tion commonly called harden- 
ing of the arteries, is a term 
used to describe a group of 
diseases affecting arteries in 
a particular way. 
Atherosclerosis applies 
specifically to arteriosclerosis 
that affects large arteries. "It 
is the underlying pathologic 
condition in most cases of 
coronary heart disease, aortic 
aneurysm, peripheral 
vascular disease, and 
stroke. . . Atherogenesis is 



111 



the process that culminates in 
atherosclerosis." (3, p. 3) 

Arteriosclerosis, besides its 
outstanding contribution to 
cases of stroke and heart 
disease, is directly responsi- 
ble for a number of deaths. 
While its direct contribution to 
the total death rate is not of 
the same magnitude as 
stroke and heart disease, it is 
still among the 10 leading 
causes of death. The age- 
adjusted death rates for this 
cause of death were similar 
for whites, nonwhites, and 
blacks. In 1980, the number 
of deaths per 100,000 
population among whites, 
nonwhites, and blacks were 
5.6, 5.9, and 6.4, 
respectively (see Table 6 and 
reference 2). 

While the age-adjusted 
death rate for this cause is 
slightly higher among blacks 
than whites, the proportion of 
deaths from this cause is 
higher for whites. It ranked 
eighth among leading causes 
for whites in 1980 compared 
with a ranking of twelfth for 
blacks (see Table 1). The dif- 
ference in the relationship is 
probably due to the younger 
age distribution of blacks, 
which is accounted for in 
age-adjusted death rates 
(from reference 2) but not in 
the number of deaths 
(Table 1). 
4. Hypertension 
"An estimated 60 million 
Americans have high blood 
pressure that increases their 
risk of illness and premature 
death. . Untreated hyperten- 
sion is the largest single con- 
tributor to stroke and a major 
contributor to heart disease 
and kidney failure." (12) 

Based on data from 
NAMCS, an estimated 25.1 
million visits to office-based 
physicians were made by pa- 
tients with essential hyperten- 
sion in 1980. Also, "during 
1980, hypertension was the 
leading illness related prin- 



cipal diagnosis and ac- 
counted for 9 percent of all 
visits." (13, p. 1) 

Findings of the latest large 
scale sample of blood 
pressure ratings "indicate 
that there has been an in- 
creased awareness, treat- 
ment, and control of 
hypertension during the 
1970's." (14) Blood pressure 
readings have been taken 
over the past 20 years by 
NCHS as part of eight 
surveys, four of which are 
presented in Tables 7 and 8. 
The three time periods are: 

1) Earliest Period— 1 960- 
1962, data from the first Na- 
tional Health Examination 
Survey (NHES I); 

2) More Recent Period— 
1971-1975, the first National 
Health and Nutrition Ex- 
amination Survey (NHANES I), 
or 1974-1975, the first Na- 
tional Health and Nutrition 
Examination Augmentation 
Survey (NHANES IA); and 

3) Most Recent Period— 
1976-1980, the second Na- 
tional Health and Nutrition 
Examination Survey 
(NHANES II). 

Hypertension, also re- 
ferred to as elevated blood 
pressure, is defined as a 
systolic reading of at least 
160 and or a diastolic 
reading of at least 95 (15, 
p. 4; 16, p. 11; 14, p. 9). The 
prevalence rate of definite 
hypertension per 100 popula- 
tion for each 10-year age 
group for three time periods 
is presented in Table 7. 

As with many chronic con- 
ditions, the prevalence rates 
of hypertension increase with 
age. At younger age levels a 
higher prevalence of 
hypertension is found among 
males than females but the 
reverse occurs at older ages. 
The crossover among blacks 
occurs at an earlier age (45, 
compared with 55 for whites) 



and is less consistent than for 
whites (see Table 7). At every 
age level, for each time 
period, and for both sexes, 
the reported prevalence rate 
of hypertension is higher, 
and usually substantially 
higher, among blacks than 
whites. 

Age-adjusted prevalence 
rates are presented in Table 
8 for the four race/sex 
groups and three time 
periods. The trend for these 
three time periods is inconsis- 
tent. The 1976-1980 
prevalence rates are similar 
to the 1960-1962 rates and 
lower than the 1974-1975 
rates. Since the standard er- 
rors for 1974-1975 were 
large, comparisons will be 
made of 1960 and 1980 on- 
ly. In 1960, black males and 
black females had almost 
twice the prevalence rates of 
white males and white 
females. In 1980, however, 
while black females had 
almost twice the rate as white 
females, black males had 
only one and one-third the 
prevalence rate of hyperten- 
sion as white males. 

Interpretation and com- 
parisons over time are com- 
plicated by the inclusion of 
persons who are taking 
medication for hypertension 
in the hypertension category 
(even if their levels are below 
160), since their hypertension 
is controlled. Perhaps a 
cleaner comparison may be 
made by referring to the "on 
medication and controlled" 
column of Table 8, where a 
more consistent pattern of in- 
creases in this category is 
seen from the first through 
the third survey. From 
1960-1962 to 1976-1980, 
among white men, white 
women, and black women, 
roughly twice as many were 
on medication and controlled 
in 1976-1980 compared with 
1960-1962. Among black 
men, three times as many 
were medicated and con- 
trolled in the latest time 



period compared with the 
earliest time period. However, 
black men still have the 
lowest rate of hypertension 
control, 16.1 compared with 
40.3 for white women, 38.3 
for black women, and 20.9 
for white men. While in- 
creased control of hyperten- 
sion has occurred over time 
among blacks, the differential 
stills exists. 

The National High Blood 
Pressure Education Program 
(NHBPE) was begun in 1972 
and had as its goal decreas- 
ing the number of people 
with elevated blood pressure 
by 50 percent every 5 years. 
It has been suggested that 
". . . more emphasis needs 
to be placed on research in- 
vestigating probable 
biological differences at- 
tributable to ethnicity ..." 
and that there exists a need 
for racially differentiated 
preventive and treatment 
modalities (17). 

While differentiated 
preventive and treatment 
modalities have not been in- 
stituted on any large scale, 
research investigating 
biological differences at- 
tributable to ethnicity has a 
head start due to the exten- 
sive data collection efforts on 
the part of the National 
Center for Health Statistics. 
The first National Health and 
Nutrition Examination Survey 
(1971-1974) provides a rich 
source of relevant data (18). 
The size of the sample and 
the oversampling of high risk 
groups provides a means of 
comparing those groups. 
While no new variables were 
added, data from the survey 
strongly confirm some of the 
previously described relation- 
ships between blood 
pressure and obesity, dietary 
salt intake, and alcohol con- 
sumption, in addition to 
cigarette smoking, oral con- 



112 



traceptive use, and psycho- 
logical status. 

Two survey findings were 
of particular interest. 1) The 
influence of obesity on 
hypertension is similar in 
white and black persons and 
males and females in the 
United States. 2) The 
sodium/potassium ratio, 
Na/K, "was observed to be 
related to blood pressure in 
Black but not White persons, 
and, when Na/K was con- 
trolled, the Black/White dif- 
ferences in pressure were 
minimized or eliminated." 
(18, p. 24) 

A panel of medical ex- 
perts armed only with the 
published results of this 
■survey might produce an 
outline for a differential 
hypertension control program 
for blacks. Emphasis on 
reducing the 
sodium/potassium ratio, 
possibly by increasing potas- 
sium intake, might be one 
facet of a differentiated 
preventive program for 
blacks. 

5. Risk Factors of Major 
Cardiovascular Diseases 

The four diseases 
comprising the major 
cardiovascular disease 
category (heart disease, 
cerebrovascular disease, 
arteriosclerosis, and 
hypertension) are interrelated. 
Since they are all diseases of 
the heart and blood vessels, 
it is natural that the occur- 
rence of one of the four 
disease conditions in an in- 
dividual increases the 
likelihood of the occurrence 
of one or more of the other 
three. We have mentioned 
that hypertension and 
arteriosclerosis are both risk 
factors for heart disease and 
stroke. The following excerpt, 
which attempts to define and 
describe risk factors 
associated with car- 
diovascular disease, sheds 
some light on the interrela- 



tionship of these four disease 
categories. 

"Since risk factors are 
based on associations un- 
covered in epidemiologic 
studies, a risk factor may be 
a causative agent, a second- 
ary manifestation of an 
underlying metabolic abnor- 
mality or an early symptom of 
disease. . . .Among the risk 
factors, the three that best 
satisfy these criteria are 
hypercholesterolemia, 
hypertension, and cigarette 
smoking. As to the role of a 
diet high in cholesterol and 
saturated fat as a risk factor, 
the relationship is well 
established for population 
groups, and less consistently 
so for individuals within 
populations, although recent 
data are confirmatory for in- 
dividuals as well . . . Other 
characteristics that are less 
strongly or less consistently 
associated with the probabil- 
ity of developing coronary 
heart disease are often re- 
ferred to as probable or 
suspected risk factors. They 
include physical inactivity, 
personality behavior type, 
and a high concentration of 
blood glucose without overt 
diabetes mellitus." (3, p. 16) 

C. Malignant Neoplasms 

"The social and economic 
implications of cancer for vic- 
tims and the society at large 
are pain, suffering, disability, 
and death; millions of years 
of life lost; vast amounts of 
human and economic 
resources devoted to detec- 
tion, diagnosis, and treat- 
ment; and billions of dollars 
of economic output foregone 
annually because of lost 
human resources." (19, p. 1) 
The suffering experienced by 
the victims of this disease, 
families of the victims, and 
the remainder of the popula- 
tion who live in dread of this 
disease is indescribable. 
Available cancer morbidity 



and mortality data will be 
used in this section to com- 
pare the impact of this 
disease on minorities and on 
the remainder of the 
population. 

1. Incidence— All Sites 

Figures 1 and 2 contain 
cancer incidence rates for 
whites and for racial and 
ethnic minority groups. The 
National Cancer Institute has 
a program that deals with the 
surveillance, epidemiology, 
and end results (SEER) of 
cancer. SEER provides data 
covering about 10 percent of 
the U.S. population. Data 
from this program are con- 
tained in Figures 1 and 2. 
Based on rates found in 
these exhibits, the ranking of 
American ethnic groups from 
high to low cancer incidence 
rates is as follows: 



2. Incidence— Selected 
Sites 

In examining individual 
cancer sites separately, the 
following racial/ethnic dif- 
ferences in incidence rates 
were found: 

1 . Esophageal cancer- 
Black males have an in- 
cidence rate four times that 
of white males (see Figure 4). 

2. Stomach cancer— Among 
males, the rates for blacks, 
hispanics, and American In- 
dians are higher than those 
for whites (20). 

3. Cancer of the colon— 
Among both sexes, lower 
rates were found in Hispanic 
and American Indian popula- 
tions, and higher or similar 
rates among Chinese, 
Japanese, blacks, and whites 
(see Figure 5). 

4. Pancreatic cancer — 



Rank Males 


Rank Females 


1. 


Hawaiian 


1. 


Hawaiian 


2. 


Black 


2 


White 


3. 


White 


3. 


Black 


4.5 


Japanese- 


4. 


Chinese- 




Hawaii 




San Francisco 


4.5 


Chinese- 


5. 


Chinese- 




San Francisco 




Hawaii 


6. 


Chinese- 


6. 


Hispanic- 




Hawaii 




New Mexico 


7. 


Filipino 


7. 


Japanese- 








San Francisco 


8.5 


Hispanic- 


8. 


Japanese- 




Puerto Rico 




Hawaii 


8.5 


Hispanic- 


9.5 


American 




New Mexico 




Indian 


10. 


Japanese- 


9.5 


Filipino— 




San Francisco 




San Francisco 


11. 


American 


11. 


Hispanic- 




Indian 




Puerto Rico 



Black males had higher in- 
cidence rates than white 
males, while black females 
had lower incidence rates 
than white females, as shown 
above and in data presented 
in Figures 1 and 2. Similar 
findings were observed in 
three National Cancer 
Surveys, as well as from the 
SEER program for another 
time period (20, p. 21). 



Among males, blacks have a 
higher incidence rate than 
whites (20). 

5. Lung cancer— Black 
males have higher incidence 
rates than white males. 
Hispanics have relatively low 
incidence rates (see Figure 
6). 



113 



Figure 1 

Average annual age-adjusted cancer incidence rates (all sites) for males by 
race, SEER program, 1973-1977. Age-adjusted to the 1970 U.S. Population. 

Rate per 100,000 

0 100 200 300 400 500 



Whites 



Blacks 

Hispanics- 
Puerto Rico 

Hispanics- 
New Mexico 

American 
Indian 

Chinese- 
San Francisco 

Chinese- 
Hawaii 

Japanese- 
San Francisco 

Japanese- 
Hawaii 



Filipino 



Hawaiian 



1 00 


200 


300 


400 























































































































































































































Figure 2 

Average annual age-adjusted cancer incidence rates (all sites) for females by 
race, SEER program, 1973-1977. Age-adjusted to the 1970 U.S. Population. 

Rate per 100,000 



0 



Whites 



Blacks 

Hispanics- 
Puerto Rico 

Hispanics- 
New Mexico 

American 
Indian 

Chinese- 
San Francisco 

Chinese- 
Hawaii 

Japanese- 
San Francisco 

Japanese- 
Hawaii 



Filipino 



Hawaiian 



100 


200 


300 




— — , — — 


m 






















I— HI 



































































































400 



500 



Source: The National Cancer Institute, Surveillance, Epidemiology, and End Results 
Program (SEER). Taken from "Cancer in Minorities" by John L. Young in Behavior, 
Health Risks, and Social Disadvantage, Summary of a Conference, edited by Delores L. 
Parron, Frederic Solomon, and David Jenkins. Institute of Medicine. National Academy 
Press, Washington, DC, 1982. 



Source: The National Cancer Institute, Surveillance, Epidemiology, and End Results 
Program (SEER). Taken from "Cancer in Minorities" by John L. Young in Behavior, 
Health Risks, and Social Disadvantage, Summary of a Conference, edited by Delores L. 
Parron, Frederic Solomon, and David Jenkins. Institute of Medicine. National Academy 
Press, Washington, DC, 1982. 



6. Breast cancer— Breast 
cancer is the most common 
form of cancer among 
females in every ethnic group 
(20), Whites have a higher in- 
cidence rate than blacks (see 
Figure 7), 

7. Prostatic cancer— The in- 
cidence of prostate cancer is 
higher in black males than in 
white males. It is the most 
common form of cancer in 
black males (20) (see Figure 
8). 

3. Mortality— All Sites 

Cancer was the second 
leading cause of death in the 
United States in 1980, 
accounting for roughly one 
out of five deaths for the total 
population and for both racial 
groups (see Table 1). 



The relative position of the 
four race/sex groups with 
regard to age-adjusted death 
rates from cancer has 
changed between 1950 and 
1980 (see Table 9, Figure 3, 
and rates listed below). 



1950 

Rank Racial Group 

1. All other females (131.0) 

2. White males (130.9) 

3. All other males (125.8) 

4. White females (119.4) 

1980 

Rank Racial Group 

1. All other males (209.0) 

2. White males (160.5) 

3. All other females (120.2) 

4. White females (107.7) 



While rates for both white 
and nonwhite males were 
somewhat close in 1950, and 
rates for both groups have 
increased throughout the en- 
suing 30 years, the rates for 
nonwhite males have in- 
creased much more substan- 
tially during this period. While 
nonwhite females had the 
highest age-adjusted death 
rate from cancer in 1950, 
males of all other races had 
the highest rate in 1980. 
Nonwhite males have ex- 
perienced a steady and 
steep increase in mortality 
from cancer, surpassing the 
rate for whites in 1959 and 
steadily climbing (see Figure 
3). The gap in the cancer 



mortality rates between 
minorities has been broaden- 
ing among males. 

A different picture 
emerges for females. While 
death rates for males have 
been climbing, the same 
30-year period has witnessed 
a decline in cancer death 
rates for females. In 1950, 
death rates of females in 
both racial groups were in 
the same range as those for 
males. White females had 
lower rates than nonwhite 
females, and the discrepancy 
was slightly larger than that 
for males. Even though death 
rates have fallen among 
females of both racial groups, 
the disparity has been 



114 



preserved. During the shorter 
period from 1970 to 1980, 
cancer mortality among 
whites increased minimally 
(1 .4 percent) but more 
substantially among all other 
races (6.7 percent). 
4. Mortality— Selected Sites 
Cancers of the digestive and 
respiratory systems combined 
were responsible for roughly 
half of all cancer deaths in 
1980. Cancer of the digestive 
system combined with cancer 
of the genital organs and 
breast cancer accounted for 
almost three quarters of all 
cancer deaths in the same 
year. In Table 10 crude 
death rates for these four 
sites, for all cancer sites, and 
for all causes of death are 
presented for the years 1970 
and 1980. 

While death rates from all 
causes (cancer plus all other 
causes) decreased, death 
rates from cancer increased 
during this 10-year period for 
each racial/sex group at a 
rate of 12 to 14 percent. The 
greatest increase in death 
rates occurred in cancer of 
the respiratory system. The 
rate of increase was highest 
among white females and 
lowest among white males. 
There was a larger increase 
in breast cancer among non- 
white females than among 
white females, but white 
females continue to have 
higher death rates from 
breast cancer than nonwhite 
females (32.3 versus 20.5). A 
greater drop in cancer of the 
genital organs was ex- 
perienced by nonwhite 
females (19.2 percent) than 
by white females (9.6 per- 
cent). This differential rate of 
decrease resulted in a slightly 
lower death rate in nonwhite 
females than white females 
(18.5 versus 19.7) in 1980, 
while the reverse was true in 
1970 (22.98 versus 21.8). A 
greater increase in cancer of 
the genital organs was ex- 
perienced by nonwhite males 



Figure 3 

Age adjusted mortality rates, all malignant neoplasma in 
Whites 



Age adjusted mortality rates, all malignant neoplasma in 
Nonwhites 



Male 

Rates per 
100,000 

1950 

280 
260 
240 
220 
200 
180 
160 
140 
120 
100 

80 

60 

40 

20 
0 



Female 



1955 



Calendar Years 

1960 1965 



1970 1975 



Male 

Rates per 
100,000 

1950 

280 
260 
240 
220 
200 
180 
160 
140 
120 
100 

80 

60 

40 

20 
0 



Female 



1955 



Calendar Years 

1960 1965 1970 1975 



'Age-adjusted rate as percent ot age-adjusted rate for all malignant neoplasms. 
Includes: (ICD 140-205) [6th]; ICD 140-205 [7th]; ICD 140-207.9 [8th]) 
Source: Cancer Mortality in the United States: 1950-1977. NCI Monograph 59. 
U.S. Department ot Health and Human Services (PHS). NIH Publication No. 82-2455 
U.S. Government Printing Office, Washington, DC, 1982. p. 2. 



than by white males. Cancer 
of the digestive system in- 
creased for each racial/sex 
group with females of non- 
white races experiencing the 
greatest increase. 

Age-adjusted site-specific 
cancer mortality rates were 
published for 1980 (2, p. 31) 
but not for 1970, and are 
therefore not included in 
Table 10. Since data in Table 
10 are used for comparisons 
over time, crude rates, 
although not ideal, may be 
acceptable if it can be 
assumed that drastic 
changes did not occur in the 
age distribution between 
1970 and 1980. 

To provide measures of 
the relative differences bet- 
ween these two racial 
groups, however, age- 
adjusted rates provide more 
accuracy. These are available 
for 1980 (2, p. 31) and were 
used to calculate ratios of 
nonwhite-to-white mortality 



rates by cancer site as 
shown below. For com- 
parison purposes, ratios were 
also calculated using crude 
death rates. 

Ratios of Nonwhite-to- 
White Mortality Rates— 1980 



above with the exceptions of 
breast and respiratory 
cancer. The breast cancer 
mortality rate of nonwhite 
females is lower than that of 
white females whether crude 
or age-adjusted rates are 



Crude 
Male Female 



Age-Adjusted 
Male Female 



Respiratory 


.85 


.66 


1.27 


.99 


Breast 




.63 




.93 


Genital 


1.23 


.94 


1.90 


1.40 


Digestive 


.97 


.78 


1.46 


1.31 


All cancers 


.88 


.73 


1.30 


1.12 


All causes 


.95 


.82 


1.36 


1.42 



With only one exception, 
genital cancer among males, 
nonwhite mortality rates are 
lower than white mortality 
rates when rates are not ad- 
justed. With the use of age- 
adjusted rates, however, mor- 
tality rates are higher among 
nonwhites than whites for all 
cancers combined, for all 
causes of death combined, 
and for each site included 



used for the racial com- 
parison. The differential is 
greater, however, when 
crude rates are used. 

Among both males and 
females, the greatest racial 
differential was found for 
cancer of the genital organs 
when age-adjusted rates are 
used. Using crude rates, the 



115 



I 



Figure 4 

Average annual age-adjusted cancer of the esophagus incidence rates for 
males by race, SEER program, 1973-1977. Age-adjusted to the 1970 U.S. 
Population. 



Rate per 100,000 



Whites 



Blacks 

Hispanics- 
Puerto Rico 

Hispanics- 
New Mexico 

American 
Indian 

Chinese- 
San Francisco 

Chinese- 
Hawaii 

Japanese- 
San Francisco 

Japanese- 
Hawaii 



5 


10 


15 

























































































































20 



25 



Filipino 



Hawaiian 



Source: The National Cancer Institute, Surveillance, Epidemiology, and End Results 
Program (SEER). Taken from "Cancer in Minorities" by John L. Young in Behavior, 
Health Risks, and Social Disadvantage, Summary of a Conference, edited by Delores L. 
Parron, Frederic Solomon, and David Jenkins. Institute of Medicine. National Academy 
Press, Washington, DC, 1982. 



Figure 5 

Average annual age-adjusted cancer of the colon incidence rates for males 
by race, SEER program, 1973-1977. Age-adjusted to the 1970 U.S. Population. 

Rate per 100,000 



0 



Whites 



Blacks 

Hispanics- 
Puerto Rico 

Hispanics- 
New Mexico 

American 
Indian 

Chinese- 
San Francisco 

Chinese- 
Hawaii 

Japanese- 
San Francisco 

Japanese- 
Hawaii 



10 


20 


30 


40 











































































































































50 



Filipino 



Hawaiian 



Source: The National Cancer Institute, Surveillance, Epidemiology, and End Results 
Program (SEER). Taken from "Cancer in Minorities" by John L. Young in Behavior, 
Health Risks, and Social Disadvantage, Summary of a Conference, edited by Delores L. 
Parron, Frederic Solomon, and David Jenkins. Institute of Medicine. National Academy 
Press, Washington, DC, 1982. 



greatest racial differential was 
found for cancer of the 
genital organs when age- 
adjusted rates are ratioed. 
Using crude rates, the 
greatest differential among 
males was for cancer of the 
genital organs, but among 
females the site with the 
greatest racial differential was 
breast cancer. 
5. Risk Factors of Cancer 
"There seems to be general 
agreement among resear- 
chers that the majority of 
cancers are related to en- 
vironmental exposures, even 
though experts differ on the 
relative importance of such 
factors. Substances or condi- 



tions known to be related to 
the risk of cancer are tobac- 
co, alcohol, high fat diet, 
asbestos, drugs, suppression 
of immune capacity, and 
ionizing radiation." (21 , 
p. 137) 

"Some researchers 
suspect that genetic in- 
fluences predisposing to risk 
for certain cancers may also 
be associated with 
socioeconomic status or fac- 
tors highly correlated with 
socioeconomic status. These 
linkages have not been iden- 
tified as clearly as the 
associations with exposure to 
factors in the environment. 
Research on genetic factors 
is expected to improve 



understanding of the cancer 
differentials among 
racial/ethnic populations. A 
recent National Cancer In- 
stitute study has documented 
the fact that Hispanics 
develop at least one-third 
fewer cancers than other 
Americans. Among the possi- 
ble explanations for this are 
genetic factors, although the 
strongest contributing factors 
seem to be associated with 
life styles, especially diet. 
There is good evidence that 
a diet high in animal and 
dairy fats causes an increase 
in some cancers, especially 
of breast and colon. Poverty 
and tradition have produced 



an Hispanic diet high in pro- 
teins from legumes rather 
than from meat." (21, p. 137) 

"Social epidemiologic 
research has found that, 
even under conditions of 
egual employment, minorities 
experience differential ex- 
posure to pathogenic 
agents." (21, p. 136) Blacks 
and other minorities, to a 
larger degree than the total 
population, have been 
employed at the lowest paid, 
dirtiest, and least desirable 
jobs. That these types of jobs 
should also be more hazard- 
ous to health is not only ob- 
vious but also documented. 

1. Blacks working in steel 
mills have higher cancer 



116 



Figure 6 

Average annual age-adjusted lung cancer incidence rates for males by race, 
SEER program, 1973-1977. Age-adjusted to the 1970 U.S. Population. 



25 



Rate per 100,000 

50 75 



100 



125 



Figure 7 

Average annual age-adjusted breast cancer incidence rates for females by 
race, SEER program, 1973-1977. Age-adjusted to the 1970 U.S. Population. 



25 



Rate per 100,000 

50 75 



100 



125 



Whites 



Blacks 

Hispanics- 
Puerto Rico 

Hispanics- 
New Mexico 

American 
Indian 

Chinese- 
San Francisco 

Chinese- 
Hawaii 

Japanese- 
San Francisco 

Japanese- 
Hawaii 



Filipino 



Hawaiian 



Whites 



Blacks 

Hispanics- 
Puerto Rico 

Hispanics- 
New Mexico 

American 
Indian 

Chinese- 
San Francisco 

Chinese- 
Hawaii 

Japanese- 
San Francisco 

Japanese- 
Hawaii 



Filipino 



Hawaiian 



Source: The National Cancer Institute, Surveillance, Epidemiology, and End Results 
Program (SEER). Taken from "Cancer in Minorities" by John L. Young in Behavior, 
Health Risks, and Social Disadvantage, Summary of a Conference, edited by Delores L. 
Parron, Frederic Solomon, and David Jenkins. Institute of Medicine. National Academy 
Press, Washington, DC, 1982. 



Source: The National Cancer Institute, Surveillance, Epidemiology, and End Results 
Program (SEER). Taken from "Cancer in Minorities" by John L. Young in Behavior, 
Health Risks, and Social Disadvantage, Summary of a Conference, edited by Delores L. 
Parron, Frederic Solomon, and David Jenkins. Institute of Medicine. National Academy 
Press, Washington, DC, 1982. 



death rates than whites. 
Employment data reveal that 
disproportionate numbers of 
blacks are concentrated in 
the coke ovens, which are 
the greatest source of car- 
cinogenic exposure in the 
steel industry. 

2. Disproportionate 
numbers of blacks work in 
the mixing and compounding 
area of Akron rubber works 
plants, and "mixing and 
compounding workers have 
elevated rates of stomach, 
lung, blood, bladder, and 
lymphatic cancer." (22, 

p. 44). 

3. Conversely, "until 
relatively recently few blacks 
were employed in New 
Jersey's synthetic organic 



chemical and dye industry. 
While males throughout the 
state suffer disproportionately 
high bladder cancer rates, 
black males have been, for 
the most part, spared this 
epidemic." (22, p. 45) 

"In order to better under- 
stand the health risk minority 
workers face, epidemiologists 
must begin to place a priority 
on studying minority workers 
within largely white cohorts, 
as well as in those industries 
and job titles in which 
minorities are over- 
represented. We must also 
begin to study the relation- 
ship between occupation and 
other societal risk factors, in- 
cluding malnutrition and 



childhood disease. These are 
long-term research goals and 
cannot substitute for im- 
mediate preventive programs. 
Minority workers still assigned 
to the most hazardous and 
least desirable jobs cannot 
wait for epidemiology to con- 
firm that their jobs are killing 
them." (22, p. 147) 

D. Diabetes 

Diabetes was the seventh 
leading cause of death in the 
United States in 1980, 
accounting for about 2 per- 
cent of all deaths. "Diabetics 
have more severe 
atherosclerosis, twice as 
many heart attacks and 
about twice as many strokes 
as nondiabetics of the same 
age." (10, p. 59) Diabetes 



"is associated with 50 per- 
cent of all amputations 
among adults, 20 percent of 
all cases of kidney failure, 
and 15 percent of all cases 
of blindness." (23, 
p. 20) 

The most feared outcome 
of the disease is diabetic 
acidosis or coma brought on 
by severe water depletion 
and electrolyte changes. 
"Before the discovery of in- 
sulin almost half (48 percent) 
of all diabetics died in coma. 
This figure has now dropped 
to 1 .2 percent. Most diabetics 
now die of the complications 
of the disease, deterioration 
of kidneys and arteries or 
changes in the nervous 



117 



Figure 8 

Average annual age-adjusted prostate cancer incidence rates for males by 
race, SEER program, 1973-1977. Age-adjusted to the 1970 U.S. Population. 

Rate per 100,000 



Whites 



Blacks 

Hispanics- 
Puerto Rico 

Hispanics- 
New Mexico 

American 
Indian 

Chinese- 
San Francisco 

Chinese- 
Hawaii 

Japanese- 
San Francisco 

Japanese- 
Hawaii 



Filipino 



Hawaiian 



25 


50 























































































































75 



100 



125 



Source: The National Cancer Institute, Surveillance, Epidemiology, and End Results 
Program (SEER). Taken from "Cancer in Minorities" by John L. Young in Behavior, 
Health Risks, and Social Disadvantage, Summary of a Conference, edited by Delores L. 
Parron, Frederic Solomon, and David Jenkins. Institute of Medicine. National Academy 
Press, Washington, DC, 1982. 



system. With insulin it is easy 
to keep the average diabetic 
patient alive for a long period 
of years, but little is known 
about how to prevent the 
serious complications that oc- 
cur so frequently among 
diabetics." (24, p. 287) 

Diagnoses of new cases 
of diabetes are occurring at 
about 600,000 cases a year 
(23). In 1973 (the last data 
year for which prevalence 
rates were published by 
race), according to the 
Health Interview Survey, the 
reported prevalence rate per 
1,000 population among 
whites was 19 9 and among 
all other races 23.9 (25). 
Slightly more current 
prevalence rates for the four 
racial/sex groups are 
presented in Table 1 1 . 
Among whites, age-adjusted 
prevalence rates are similar 
for males and females, but 
among nonwhites, age- 
adjusted diabetes prevalence 
rates are considerably higher 
for females than for males. 
The age-adjusted prevalence 
rate among nonwhite females 
(36.6) is 76.0 percent higher 
than the rate among white 
females (20.8). 
"Patients with diabetes 
mellitus made up about 9.6 
million visits to office-based 
physicians in 1980." (6) In 
Table 12, details regarding 
physician visits for this condi- 
tion are presented. Sixteen 
percent of all visits for 
diabetes were made by 
blacks, a percentage 
disproportionate with their 
distribution in the population 
(12 percent). This disparity 
might be even greater if visits 
to other settings, such as out- 
patient departments, were 
included. 

Hospitalizations for 
diabetes increased in number 
for both whites and non- 
whites between 1975 and 
1981 (see Table 3), but as a 
percentage of discharges for 



all causes, they have only in- 
creased a tenth of a percent 
for each race. In 1981, the 
proportion of total discharges 
represented by this disease 
among races other than 
white was 2.2* percent, which 
is higher than that for whites 
(1 .6 percent). 

Although the age-adjusted 
death rate from diabetes 
decreased 29.4 percent be- 
tween 1950 and 1980 (see 
Table 13), increases in the 
death rate also occurred dur- 
ing this period. A consistent 
downward trend in diabetes 
death rates was observed in 
one group only, white 
females. Between 1970 and 
1980, however, both racial 
groups experienced a 
decrease in death rates, with 
whites experiencing a larger 
decrease (29.5 percent), in 
comparison to all other races 
(25.4 percent). 

Diabetes prevalence is 
also excessive among 
American Indians. The ex- 
cessive prevalence among 
Indians is the subject of a 
long-term prospective study 
which began in 1965 on 
Pima Indians aged 5 years 
and older living on the Gila 
River Reservation in Southern 
Arizona (26). The age- 
adjusted death rate among 
American Indians is over 
twice that of the total popula- 
tion, 22.8 compared with 
10.0 (see Table 14). There 
was a rise in death rates 
among both American In- 
dians and all nonwhite races 
in the early 1970's, followed 
by a decline (see Figure 9). 
The rate remains highest, 
however, among American 
Indians and lowest among 
whites. 

Various committees and 
commissions have been 
established in the United 
States since 1974 to plan, 
coordinate, and implement 
programs for education and 
for control of morbidity and 
mortality from diabetes (23, 
p. 17). "There is much in- 



terest in the role of en- 
vironmental factors which 
may precipitate disease in 
genetically susceptible in- 
dividuals. Factors under in- 
vestigation include lack of ex- 
ercise, both quantitative 
(calorie intake) and qualitative 
(fiber, simple sugar, etc.) 
aspects of diet, obesity, and 
psychosocial stress. The 
varying rural/urban gradient 
noted in studies in this region 
suggest an interaction be- 
tween genetic and en- 
vironmental factors in the 
causation of diabetes." (27, 
p. 80) 

E. Chronic Respiratory 
Conditions 

The most recent chronic non- 
tubercular respiratory condi- 



tion prevalence data by race 
from the National Health In- 
terview Survey were 
published in 1974, and were 
included in the 1979 edition 
of Health Status of Minorities 
and Low Income Groups (28, 
pp. 106-107). At that time 
some of the most prevalent 
conditions were chronic 
sinusitis, hay fever, and 
hypertrophy of tonsils and 
adenoids. Nonwhites had 
lower prevalence rates for 
almost all of the 15 leading 
chronic, nontubercular, 
respiratory conditions. 

The converse is true in the 
case of tuberculosis, for 
which prevalence rates are 
considerably higher among 
the disadvantaged. Tuber- 



118 



Figure 9 

Age-adjusted diabetes mellitus death rates. 

Per 100,000 
Population 

1955 

40 



30 



20 



10 




Source: FY 1984 Budget Appropriation Indian Health Service "Chart Series". Vital 
Events Branch, Office of Program Statistics, Division of Resource Coordination. Indian 
Health Service, Rockville, MD, April 1983. 



culosis morbidity is presented 
in Table 15 for Indian and 
Alaska Natives, as well as for 
other racial comparison 
groups. The racial group ex- 
periencing the greatest 
decline in morbidity between 
1971 and 1981 was the In- 
dian and Alaska Native. The 
case rate of tuberculosis in 
1971 was 157.4 per 100,000 
population, a rate almost 
three times greater than the 
rate in 1981 (54.1 cases per 
100,000 population). The 
racial differential in 1981 was 
still substantial. Indian and 
Alaska Natives had almost 
four and a half times the 
case rate (54.1) as all races 
(1 1 .9) in the United States, 
while nonwhites had over 
three times the case rate 
(37.6) as had all races com- 
bined (11.9). 

A similar situation exists 
with regard to tuberculosis 
mortality (see Table 16). 
While the age-adjusted mor- 
tality rate from tuberculosis 
among Indian and Alaska 



Natives in 1969 (16.1 deaths 
per 100,000 population) was 
roughly two and a half times 
the mortality rate in 1979 (4.4 
deaths per 100,000 popula- 



tion), the rate was still over 
six times that of the total U.S. 
population (0.7). While there 
is room for improvement, a 
considerable reduction in 
both morbidity and mortality 
from tuberculosis has been 
experienced by Indian and 
Alaska Natives. "This amaz- 
ing improvement in the tuber- 
culosis situation among the 
Indians and Alaskan Natives 
is due primarily to the 
dedicated efforts of the staff 
of the Indian Health Service. 
Active cases of tuberculosis 
have been subjected to 
careful regimes of chemo- 
therapy, while family and 
other contacts have 
undergone prophylactic ther- 
apy with isoniazid" (24, 
p. 229) 

A comparison of the mor- 
bidity and mortality ratios of 
Indians and of nonwhites (as 
calculated from morbidity and 
mortality rates found in 
Tables 15 and 16) is shown 
below. The entries are ratios 
of "Indian and Alaska 
Natives/All Races" and 
"Nonwhites/AII Races." 



Figure 10 

Tuberculosis cases in large cities, United States, 1976. 



Distribution of Cases 



Size of City Number 
(population) of Cases 



Case 
Rate* 







500,000* 


8,669 


28.3 


54% 


27% \ 


250,000 to 
500,000 


3,117 


24.5 






100,000 to 










250,000 


2,904 


17.8 




\ \io% / 
\ 9% y 


All other 
areas 


17,415 


11.2 



United 
States 



32,105 



15.0 



'Per 100,000 population 

Source: Tuberculosis cases in large cities. United States 1976. Center for Disease 
Control. 1976. Tuberculosis in the United States HEW publication No. (CDC) 78-8322. 
Taken from Public Health and Community Medicine 3rd edition by Lloyd Edward 
Burton, Hugh Hollingsworth Smith, and Andrew Wilkinson Nichols. Williams and 
Wilkins, Baltimore/London 1980. 



Indians Nonwhites 
Morbidity 

1979 4.48 3.14 

1969 7.37 3.13 

Mortality 

1979 6.29 3.57 

1969 7.00 3.48 

With regard to nonwhites in 
the United States, improve- 
ment has not been as striking 
as for Indians. While mor- 
bidity rates among nonwhites 
decreased, the morbidity dif- 
ferential (ratio of nonwhites to 
all races) remained roughly 
the same for 1969 and 1979 
and the mortality differential 
increased. "Susceptibility to 
tuberculosis is probably in- 
herited on a genetic 
basis. . .Certain physiological 
conditions such as malnutri- 
tion, fatigue, and diabetes 
render persons less resist- 
ant." (24, p. 277) Given 
these risk factors, particularly 
diabetes, plus the association 
of crowding and tuberculosis, 
it follows that the disadvan- 
taged would be expected to 
have a higher prevalence of 
tuberculosis. According to a 
study of differentials in 
selected health status 
measures associated with 
residents in poverty and non- 
poverty areas in 19 large 
cities, "the malnutrition, over- 
crowding, and poor sanita- 
tion, so often prevalent in ur- 
ban poverty areas, are con- 
ducive to the contraction and 
spread of infectious disease, 
particularly tuberculosis." (29, 
p. 18) The tuberculosis case 
rate is indeed higher in large 
cities where overcrowding is 
more likely to occur. The 
case rate is highest in cities 
with populations of 500,000 
and more (28.3 per 100,000 
population) and lowest in 
areas with populations under 
250,000 (11.2 per 100,000 
population) (see Figure 10). 



119 



F. Limitation of Activity 
Due to Chronic Disease 
Conditions 

Limitation of activity is a 
measure of the long-term im- 
pact of chronic illness. It is 
defined as "the inability to 
carry on the major activity for 
one's age/sex group, such as 
working, keeping house, or 
going to school, restriction in 
the amount or kind of major 
activity, or restriction in rela- 
tion to other activities, such 
as recreational, church, or 
civic interests" (30, p. 1) 

The major causes of limita- 
tion of activity are heart con- 
ditions, arthritis, rheumatism, 
hypertension, diabetes, men- 
tal and nervous conditions, 
asthma, impairments of back 
or spine, impairments of the 
lower extremities and hips, 
and visual limitations (31. 
p. 26). 

In Table 17, data based 
on crude rates from persons 
reporting limitation of activity 
due to chronic illness are 
presented by race, age, and 
income. In 1981, 26.5 per- 
cent of the population 
classified as poor (income of 
under $7,000) reported limita- 
tion of activity due to chronic 
illness, compared with 11.7 
percent of the population 
classified as nonpoor (income 
of $7,000 and over). 

A higher proportion of 
white poor (28.4 percent) 
report activity limitation than 
nonwhite poor (21.4 percent). 
Also, a higher proportion of 
white nonpoor (12.0 percent) 
report activity limitation than 
nonwhite poor (10.0 percent). 
In the total population, the 
poor are about two and one- 
guarter times as likely to 
report activity limitation as the 
nonpoor. In the white popula- 
tion, the poor are over two 
and one-third times as likely 
to have the activity limitation 
as the nonpoor. In the non- 
white population, the poor 



are about two and one- 
seventh times as likely to 
have the activity limitation as 
the nonpoor. The increases 
from 1964 to 1981 in those 
reporting limitation of activity 
are as follows: 



Percent Increase Among: 

Whites 

All other races 
All races 



In summary: 

1. Income differentials in ac- 
tivity limitation are greater 
than racial differentials. 

2. A greater increase in ac- 
tivity limitation has occurred 
among nonwhite races than 
among whites. 

3. Greater increases in activ- 
ity limitation occurred among 
the nonpoor than among the 
poor. 

These observations may 
defy explanation, but they do 
provoke comment. A larger 
percentage of chronically ill 
people in the population may 
be the tradeoff of health care 
delivery that prevents death 
without eliminating disease. 
The fact that races other than 
white have experienced 
greater increases in activity 
limitation than whites may 
mean that those races are 
receiving more of this type of 
health care. The greater in- 
crease among the nonpoor 
compared with the poor may 
also be due to more medical 
care or may be due to an 
unrefined income classifica- 
tion. The observation that in- 
come differentials in activity 
limitation are greater than 
racial differentials probably 
stems from the relationship 
between health and income. 
That is, poor health can in- 
terfere with the ability to earn 
income. 

Looking briefly at 
Hispanics, a lower proportion 



of activity limitation (based on 
crude rates) is found in this 
group. Among Hispanics only 
9.9 percent reported activity 
limitation due to chronic 
disease in 1976-1978 (see 
Table 18). 



Poor Nonpoor 

1.4 33.3 
26.6 38.9 

5.5 31.5 



120 



Table 1 

Number and percent of deaths from the 15 leading causes of death by race, United States, 1980. 







All Races 


White 






All Other 
















fot.-il 




Black 




Cause of Death and ICD Code 




No. 


% 


No. 


% 


No. 


% 


r Jo 




Diseases of the 




















Heart 390-398, 


402, 404-420 


761,085 


38.2 


683,347 


39.3 


77,738 


30.9 


72,956 


31.3 


Malignant Neoplasms 


140-208 


416,509 


20.9 


368,162 


21.2 


48,347 


19.2 


45,037 


19.3 


Cerebrovascular Diseases 


430-438 


170,225 


8.6 


148,734 


8.6 


21,491 


8.6 


20,135 


8.6 


Accidents 


E800-E949 


105,718 


5.3 


90,122 


5.2 


15,596 


6.2 


13,480 


5.8 


Chronic Obstructive Pulmonary 




















Diseases 


490-496 


56,050 


2.8 


52,375 


3.0 


3,675 


1.5 


3,380 


1.4 


Pneumonia and Influenza 


480-487 


54,619 


2.7 


48,369 


2.8 


6,250 


2.5 


5,648 


2.4 


Diabetes Mellitus 


250 


34,851 


1.8 


28,868 


1.7 


5,983 


2.4 


5,544 


2.4 


Chronic Liver Disease 




















and Cirrhosis 


571 


30,583 


1.5 


25,240 


1.5 


5,343 


2.1 


4,790 


2.1 


Atherosclerosis 


440 


29,449 


1.5 


27,069 


1.6 


2,380 


.9 


2,252 


1.0 


Suicide 


E950-E959 


26,869 


1.4 


24,829 


1.4 


2,040 


.8 


1,607 


.7 


Homicide and Legal 




















Intervention 


E960-E978 


24,278 


1.2 


13,558 


.8 


10,720 


4.3 


10,283 


4.4 


Certain Conditions Originating 




















in Perinatal Period 


760-779 


22,866 


1 . 1 


15,457 


.9 


7,409 


2.9 


6,961 


3.0 


Nephritis, Nephrotic Syndrome, 




















and Nephrosis 


580-589 


16,753 


.8 


13,137 


.8 


3,616 


1.4 


3,416 


1.5 


Congenital Anomalies 


740-759 


13,938 


.7 


11,471 


.7 


2,467 


1.0 


2,168 


.9 


Septicemia 


038 


9,438 


.5 


7,461 


.4 


1,977 


8 


1 .877 


.8 


Total (15 causes) 




1,773,231 


89.0 


1,558,199 


89 9 


215,032 


85.5 


199,534 


85.6 


Other causes 




216,560 


10.9 


180,408 


10.4 


36,202 


14.4 


33,601 


14.4 


All causes 




1,989,841 


99.9 


1,738,607 


100.3 


251,234 


99.9 


233,135 


100.0 



Source: Prepared by CHESS, based on data from the National Center for Health Statistics: U.S. Department of Health and Human 
Services, Monthly Vital Statistics Report, Advance Report of Final Mortality Statistics, 1980, Vol. 32, No. 4. Supplement, August 
1983. Tables 4 and 7. 



121 



Table 2 

Number and percent distribution of drug mentions by selected therapeutic categories, according to race and ethnicity of patient: United 
States, 1980. c= ^_____ ========== 

Race of Patient 1 Ethnicity of patient 



Black White Hispanic Non-Hispanic 



Number Number Number Number 



Selected therapeutic categories^ of Rercent of Rercent of percent of Rercent 



mentions .. . .. .. mentions , ., .. mentions , . . mentions 

distribution distribution distribution distribution 

in in in in 

thousands thousands thousands thousands 



All categories 


64,808 


100.00 


608,346 


100.00 


34,239 


100.60 


645,354 


100.00 


Antihistamine drugs 


3,565 


5.50 


39,924 


6.56 


1,602 


4.68 


42,337 


6.56 


Anti-infective agents 


9,541 


14.72 


94,050 


15.46 


6,143 


17.94 


98,755 


15.30 


Antibiotics 


8,050 


12.42 


80,818 


13.28 


5,149 


15.04 


84,931 


13.16 


Antineoplastic agents 


254 


0.39 


5,103 


0.84 


40 


0.12 


5,331 


0.83 


Autonomic drugs 


3,130 


4.83 


21,844 


3.59 


1,551 


3.71 


23,686 


3.67 


Blood formation and coagulation 


1,190 


1.84 


7,049 


1.16 


213 


0.62 


8,099 


1.25 


Cardiovascular drugs 


6,342 


9.79 


57,785 


9.50 


1,858 


5.43 


62,605 


9.70 


Cardiac drugs 


2,022 


3.12 


24,219 


3.98 


610 


1.78 


25,721 


3.99 


Hypotensive agents 


3,174 


4.90 


19,270 


3.17 


696 


2.03 


21,937 


3.40 


Vasodilating agents 


1,101 


1.70 


13,487 


2.22 


513 


1.50 


14,133 


2.19 


Central nervous system drugs . . 


1 1 ,386 


17.57 


98,137 


16.13 


6,376 


18.62 


104,330 


16.17 


Analgesics and antipyretics . 


6,697 


10.33 


50,316 


8.27 


3,112 


9.09 


54,688 


8.47 


Psychotherapeutic agents . . 


990 


1.53 


15,320 


2.52 


994 


2.90 


15,401 


2.39 


Sedatives and hypnotics . . . 


2,365 


3.65 


22,481 


3.70 


1,630 


4.76 


23,406 


3.63 


Electrolytic, caloric, and 


















water balance 


5,608 


8.65 


46,009 


7.56 


1,677 


4.90 


50,279 


7.79 


Diuretics 


4,765 


7.35 


37,862 


6.22 


1,368 


4.00 


41,466 


6.43 


Expectorants and cough 


















preparations 


2,117 


3.27 


16,553 


2.72 


1,321 


3.86 


17,578 


2.72 


Eye, ear, nose, and throat 


















preparations 


2,485 


3.83 


23,392 


3.85 


912 


2.66 


25,165 


3.90 


Gastrointestinal drugs 


2,323 


3.59 


21,581 


3.55 


1,313 


3.83 


22,827 


3.54 


Hormones and synthetic 


















substances 


5,854 


9.03 


49,503 


8.14 


3,097 


9.05 


52,746 


8.17 


Adrenals 


1,459 


2.25 


16,757 


2.75 


780 


2.28 


17,532 


2.72 


Insulins and anti- 


















diabetic agents 


1,864 


2.88 


9,117 


1.50 


712 


2.08 


10,486 


1.62 


Serums, toxoids, and vaccines . . 


1,835 


2.83 


21,555 


3.54 


1,481 


4.33 


22,230 


3.44 


Skin and mucous membrane 


















preparations 


3,998 


6.17 


50,804 


8.35 


3,033 


8.86 


52,155 


8.08 


Anti-inflammatory agents 


1,488 


2.30 


20,605 


3.39 


1,409 


4.11 


20,898 


3.24 


Spasmolytic agents 


1,172 


1.81 


10,234 


1.68 


809 


2.36 


10,732 


1.66 


Vitamins 


2,198 


3.39 


21,792 


3.58 


1,490 


4.35 


22,754 


3.53 



'Excludes data on Asians, Pacific Islanders, American Indians, and Alaska Natives. 

2 Based on the pharmacologic-therapeutic classification of the American Society of Hospital Pharmacists; selected categories 
reproduced with the Society's permission. 

Source: National Center for Health Statistics: Drug Utilization in Office-Based Practice, a summary of findings. National Am- 
bulatory Medical Care Survey, United States, 1980. Vital and Health Statistics, Series 13, No. 65. DHHS Pub No (PHS) 
83-1726. Public Health Service, Washington, DC U.S. Government Printing Office, March 1982. Table 9, p. 27, 



122 



Table 3 

Number of discharges and average length of stay for patients discharged from short-stay 
hospitals, by selected first-listed diagnostic categories and color: United States, 1975 and 1981. 



Number of 
Discharges in Average Length 
Diagnostic Category and Thousands of Stay 



ICDA Code 


Year 


White 


All Other 


White 


All Other 


i v i cm y i i&i 11 in cupiaoi no y \ '-r\j c-\j j 


1 975 


1 ,21 7 


137 


1 3.0 


1 6.0 


(140-206) 


1981 


1,705 


243 


11.5 


13.3 








7Q 


1 n o 


1 1 s 

I I . o 


(250) 


1981 


514 


141 


9.5 


10.4 


Heart Disease (410-414) 


1975 


1,507 


127 


10.8 


1 1.7 


(391-392.0, 393-398, 402, 404, 












410-416, 420-429) 


1981 


3,009 


330 


9.2 


10.2 


Cerebrovascular Disease 












(430-438) 


1975 


475 


58 


12.9 


15.7 




1981 


707 


100 


12.2 


14.2 


All Conditions 1 


1975 


25,715 


3,798 


7.7 


8.1 




1981 


32,242 


6,302 


7.2 


7.2 



1 1ncludes diagnostic conditions not shown in table. 
(Excludes newborn infants and Federal hospitals ) 

Note: Data in tables are underreported because color was not recorded on the hospital records of an estimated 4.5 million inpatients. 
Source: Compiled and abstracted by CHESS from 1 ) National Center for Health Statistics: Utilization of Short-Stay Hospitals: Annual 
Summary for the United States, 1975. DHEW Publication No. (HRA) 77-1782. Series 13. No 31. U.S. Government Printing Office, 
Washington, DC, April 1977. 2) Unpublished, National Center for Health Statistics data. 



Table 4 

Age-adjusted death rates for diseases of the heart, by color and sex: United States, selected years 
from 1950 to 1980. 



Total White All Other 



Both Both Both 

Year Sexes Male Female Sexes Male Female Sexes Male Female 



Rates per 100,000 Population 

1980 202.0 280.4 140.3 197.6 277.5 134.6 234.2 299.6 138.5 

1970 253.6 348.5 175.2 249.1 347.6 167.8 288.9 350.8 236.6 

1960 286.2 375.5 205.7 281.5 375.4 197.1 324.2 368.3 283.3 

1950 1 307.6 384.2 234.4 300.5 381.1 223.6 375.1 407.5 342.9 

For 1 950 and 1 960 rates are based on deaths assigned to category numbers 400-402. 41 0-443 of the Sixth and Seventh Revisions 
of the International Classification of Diseases adopted in 1 948 and 1 955. For 1 970 rates are based on deaths assigned to category 
numbers 390-398, 402, 404, 410-429 of the Eighth Revision For 1980 rates are based on deaths assigned to category numbers 
390-398, 402, 404-429 of the Ninth Revision of the ICD 

1 Based on enumerated population ad|usted for age bias in the population of races other than white 

Sources: 1) Department of Health, Education, and Welfare: "Mortality Trends for Leading Causes of Death, U.S. 1950-69 ." Rockville, 
Maryland, Series 20, No 16, Table P, p 41 2) Department of Health, Education, and Welfare: Monthly Vital Statistics Report, Sum- 
mary Report, Final Mortality Statistics 1970, Vol. 22, No. 8 3) Advance Report, Final Mortality Statistics, 1980. Monthly Vital Statistics 
Report, Vol. 32, No. 4, Supp. DHHS Pub. No (PHS) 83-1120. Public Health Service, Hyattsville, MD. August 1983. 



Table 5 

Age-adjusted death rates for cerebrovascular diseases, by color and sex: United States, selected years 
from 1950 to 1980. 







Total 






White 






All Other 






Rnth 






Both 






Both 






Year 


Sexes 


Male 


Female 


Sexes 


Male 


Female 


Sexes 


Male 


Female 










Rates per 100,000 Population 








1980 


40.8 


44.9 


37.6 


38.0 


41.9 


35.2 


62.9 


70.5 


57.0 


1970 


66.3 


73.2 


60.8 


61.8 


68.8 


56.2 


107.0 


113.5 


101.4 


1960 


79.7 


85.4 


74.7 


74.2 


80.3 


68.7 


134.8 


135.2 


134.4 


1950 1 


88.8 


91.9 


86.0 


83.2 


87.0 


79.7 


148.8 


144.0 


153.4 



For 1950 and 1960 rates are based on deaths assigned to category numbers 330-334 of the Sixth and Seventh Revisions of the 
International Classification of Diseases For 1970 and 1980 rates are based on deaths assigned to category numbers 430-438 of 
the Eighth and Ninth Revisions of the ICD 

1 Based on enumerated population ad|usted for age bias in the population of races other than white- 
Sources: 1) Department of Health, Education, and Welfare: "Mortality Trends for Leading Causes of Death, U S 1950-69." Rockville, 
Maryland, Series 20, No. 16, Table P, p 41 2) Department of Health, Education, and Welfare: Monthly Vital Statistics Report, Sum- 
mary Report, Final Mortality Statistics 1970, Vol. 22, No. 8. 3) Advance Report, Final Mortality Statistics, 1980. Monthly Vital Statistics 
Report, Vol 32, No 4, Supp DHHS Pub No. (PHS) 83-1120. Public Health Service, Hyattsville, MD. August 1983. 



Table 6 



Age-adjusted death rates for arteriosclerosis, by color and sex: selected years from 1950 to 1980. 






Total 


White 




All Other 






Both 




Both 


Both 






Year 


Sexes 


Male 


Female Sexes Male Female 


Sexes 


Male 


Female 








Rates per 100,000 Population 








1980 


5.7 


6.6 


5.0 5.6 6.5 5.0 


5.9 


6.8 


5.2 


1970 


8.4 


9.5 


7.5 8.4 9.6 7.5 


8.2 


9.1 


7.5 


1960 


13.2 


14.8 


11.8 13.1 14.7 11.7 


13.8 


15.5 


12.3 


1950 1 


16.2 


18.4 


14.3 16 2 18.4 14.3 


15.8 


18.0 


13.7 



For 1 950 and 1 960 rates are based on deaths assigned to category number 450 of the Sixth and Seventh Revisions of the Interna- 
tional Classification of Diseases. For 1970 and 1980 rates are based on deaths assigned to category number 440 of the Eighth 
and Ninth Revisions of the ICD. 

1 Based on enumerated population adjusted for age bias in the population of races other than white. 

Source: 1) Department of Health, Education, and Welfare: "Mortality Trends for Leading Causes of Death, U.S. 1950-1969." Rockville, 
Maryland, Series 20, No. 16. Table P, p. 41 2) Department of Health, Education, and Welfare: Monthly Vital Statistics Report. Sum- 
mary Report, Final Mortality Statistics 1970. Vol. 22. No. 8. 3) Advance Report, Final Mortality Statistics, 1980. Monthly Vital Statistics 
Report. Vol. 32, No. 4, Supp DHHS Pub. No. (PHS) 83-1120. Public Health Service, Hyattsville, MD. August 1983. 



124 



Table 7 

Prevalence rates 1 of adults 25-74 years with definite hypertension, 2 by race, age, and sex: United States: 
1960-62, 1971-75, 1976-1980. 



Age 




White 






Black 




1960-62 


1971-75 


1976-80 1960-62 


1971-75 


1976-80 








Males 








25-34 


3.6 


7.5 


8.4 


12.5 


16.4 


1 1 .7 


35-44 


11.8 


14.0 


10.6 


26.5 


36.3 


22.3 


45-54 


16.5 


22.6 


21 .2 


30.9 


36.7 


23.0 


55-64 


20.2 


25.2 


22.3 


44.6 


58.6 


39.2 


65-74 


25.0 


30.8 


24.5 


52.7 


43.3 


27.5 








Females 








25-34 


2.3 


2.2 


2.3 


8.6 


12.4 


4.3 


35-44 


6.2 


6.6 


6.5 


25.7 


23.8 


17.6 


45-54 


15.5 


13.9 


12.1 


41.3 


39.7 


37.3 


55-64 


30.6 


27.6 


18.3 


37.9 


45.6 


36.4 


65-74 


46.6 


34.9 


26.3 


64.1 


46.3 


3.4 



''Rate per 100 population. 

2 Systohc blood pressure of at least 160mm Hg and/or diastolic blood pressure of at least 95mm Hg 

Sources: Abstracted and compiled by CHESS from: 1) Hypertension and Hypertensive Heart Disease in Adults, United States. 1960-62. 
National Center for Health Statistics, DHEW Publication No. (HRA) 74-1282, Vital and Health Statistics. Series 11, No. 13. November 
1973, Table 2. 2) Hypertension in Adults 25-74 Years of Age. United States, 1971-1975. National Center for Health Statistics, DHHS 
Publication No. (PHS) 81-1671 , Vital and Health Statistics. Series 1 1 , No. 221 . April 1981 , Table 21 . 3) Blood Pressure Levels and 
Hypertension in Persons Ages 6-74 years: United States, 1976-1980. National Center for Health Statistics. DHHS Publication No. 
(PHS) 82-1250. Advance Data No. 84, October 1982, Table 5. 



Table 8 

Prevalence rates of hypertension for persons 25-74 years of age by treatment history, race, and sex with standard errors of the percent: 
United States, 1960-62, 1974-75, and 1976-80. 



Race and sex 



Hypertensive 1 



Never diagnosed^ 



On medication 



On medication and 
controlled 3 





1960-62 


1974-75 


1976-80 


1960-62 


1974-75 


1976-80 


1960-62 


1974-75 


1976-80 


1960-62 


1974-75 


1976-80 




Percent of population 4 






Percent of total with hypertension 1 ' 4 






All people 


























25-74 years 5 . . . 


20.3 


22.1 


22.0 


51.1 


36.4 


26.6 


31.3 


34.2 


56.2 


16.0 


19.6 


34.1 


White men .... 


16.3 


21.4 


21.2 


57.6 


42.3 


40.6 


22.4 


25.9 


38.3 


11.8 


15.1 


20.9 


White women . . 


20.4 


19.6 


20.0 


43.9 


29.7 


25.2 


38.2 


48.5 


58.6 


21.9 


28.1 


40.3 


Black men .... 


31.8 


37.1 


28.3 


70.5 


41.0 


35.7 


18.5 


24.0 


40.9 


5.0 


12.3 


16.1 


Black women . . 


39.8 


35.5 


39.8 


35.1 


28.9 


14.5 


48.1 


36.4 


60.6 


20.2 


22.3 


38.3 












Standard error of percent 










All people 


























25-74 years 5 . . . 


0.83 


1.26 


0.68 


1.66 


1.70 


1.53 


1.62 


2.21 


1.99 


1.65 


1.49 


2.02 


White men .... 


0.95 


2.19 


1.04 


3.75 


2.63 


1.80 


3.07 


3.22 


2.47 


2.59 


2.56 


2.01 


White women . . 


1.07 


1.14 


0.66 


2.77 


2.08 


1.97 


2.24 


3.61 


2.40 


2.24 


2.93 


2.99 


Black men .... 


3.37 


5.94 


1.86 


7.07 


10.38 


4.27 


5.53 


10.79 


4.52 


2.18 


6.69 


3.72 


Black women . . 


3.73 


3.60 


1 96 


3.72 


7.42 


2 73 


3.87 


8.30 


3.22 


3.21 


7.93 


4.35 



'Elevated blood pressure (that is, a systolic measurement of at least 160 mm Hg or a diastolic measurement of at least 95 mm 
Hg) or taking antihypertensive medication 

2 Reported never told by physician that he or she had high blood pressure or hypertension. 

3 Subset of "On medication" group; those taking antihypertensive medication whose blood pressure was not elevated at the time 
of the examination. 

4 Age adjusted by direct method to the population at midpoint of the 1976-80 National Health and Nutrition Examination Series. 

includes all other races not shown separately 

"Figure does not meet standards of reliability or precision. 

Source: National Center for Health Statistics: Blood Pressure Level and Hypertension in Persons Aged 6-74 years: United States, 
1976-80. DHHS Publication No. (PHS) 82-1250, Advance Data Number 84. U.S. Government Printing Office, Washington. DC, 
October 8, 1982, Table 7, p 10 



125 



Table 9 

Age-adjusted death rates (per 100,000 population) for malignant neoplasms, by color and sex: United 
States, selected years from 1950 to 1980. 







Total 






White 






All Other 






Both 






Both 






Both 






Year 


Sexes 


Male 


Female 


Sexes 


Male 


Female 


Sexes 


Male 


Female 










Rates per 100,000 Population 








1980 


132.8 


165.5 


109.2 


129.6 


160.5 


107.7 


158.2 


209.0 


120.2 


1970 


129.9 


157.4 


108.8 


127.8 


154.3 


107.6 


148.3 


185.3 


117.6 


1960 


125.8 


143.0 


111.2 


124.2 


141.6 


109.5 


139.3 


154.8 


125.0 


1950 1 


125.4 


130.8 


120.8 


124.7 


130.9 


1 19.4 


128.6 


125.8 


131.0 



For 1950 and 1960 rates are based on deaths assigned to category numbers 140-205 of the Sixth and Seventh Revisions of the 
International Classification of Diseases. For 1970 rates are based on deaths assigned to category numbers 140-209 of the Eighth 
Revision of the ICD. For 1980 rates are based on deaths assigned to category numbers 140-208 of the Ninth Revision of the ICD. 
1 Based on enumerated population adjusted for age bias in the population of races other than white. 

Source 1) Department of Health, Education, and Welfare "Mortality Trends for Leading Causes of Death, U.S. 1950-1969." Rockville, 
Maryland, Series 20, No. 16, Table K, p 30. 2) Department of Health, Education, and Welfare Monthly Vital Statistics Report, Sum- 
mary Report, Final Mortality Statistics 1 970, Vol. 22, No.8; 3) Advance Report, Final Mortality Statistics, 1 980. Monthly Vital Statistics 
Report. Vol. 32, No. 4, Supp. DHHS Pub. No. (PHS) 83-1120. Public Health Service, Hyattsville, MD, August 1983. 



Table 10 



Death rates of selected cancer 


sites by sex and race, 


1970 and 1980. 












White 




All Other 


Cancer Site 




Year 


Males 


Females 


Males 


Female; 


Respiratory 


(160-163) 


1970 


58.3 


13.1 


47.6 


9.5 


(Mostly lung) 


(160-165) 


1980 


73.4 


26.5 


62.5 


17.5 


Breast 


(174) 


1970 




29.9 




18.3 




(174-175) 


1980 




32.3 




20.5 


Genital Male 




1970 


18.0 




21.9 




(Mostly prostate) 


(179-187) 


1980 


20.8 




25.6 




Female 




1970 




21.8 




22.9 


(Mostly cervix, ovary, uterus) 


(180-187) 


1980 




19.7 




18.5 


Digestive (Mostly esophagus, 














stomach, colon, rectum) 


(150-159) 


1970 


51.5 


43.9 


48.7 


31.6 






1980 


52.9 


46.7 


51.2 


36.3 


All Cancers 




1970 


185.1 


149.4 


161.0 


110.0 






1980 


208.7 


170.3 


184.1 


123.6 


All Causes 




1970 


1086.7 


812.6 


1115.9 


775.3 






1980 


983.3 


806.1 


936.5 


660.6 



1970 crude death rates are based on Eighth Revision of International Classification of Diseases, 1980 rates based on Ninth Revision 
of International Classification of Diseases. 

Source: Abstracted and compiled by CHESS from 1) Final Mortality Statistics, 1970, Monthly Vital Statistics Report, DHEW Pub. 
No. (HRA) 74-1120, Vol. 22, No. 11. February 1974. Table 3. 2) Advance Report of Final Mortality Statistics, 1980. DHHS Pub. 
No. (PHS) 83-1120, Vol. 32, No. 4. Supp. August 1983. Table 8. 



126 



Table 11 

Crude and age-standardized type II diabetes prevalence rates, 
United States, 1976. 



Prevalence per 
1 ,000 Persons 



Age- 
Crude Standardized 
Rate Rate* Ratio 



All 


21.6 


21.6 


1.0 


White Males 


19.3 


20.0 


0.92 


White Females 


22.7 


20.8 


0.96 


Nonwhite Males 


21.1 


27.9 


1.29 


Nonwhite Females 


30.7 


36.6 


1.69 



Source: "The Public Health Impact of Diabetes" in Advance in Diabetes Epidemiology, 
Eveline Eschwege (Ed). INSERM Symposium No. 22. Institute Nationale de la Sante 
et de la Recherche Medicale, Elsevier Biomedical Press. Amsterdam, New York, Ox- 
ford, 1982, Table 2. 

'Age-standardized to the U.S. 1976 population. 



Table 12 



Number of office visits for diabetes mellitus, number and percent of drug visits, number of drug men- 
tions, drug mention rate, and drug intensity rate, by selected characteristics: United States, 1980. 


Selected characteristic 


Office visits 
All visits Drug visits 1 


Drug 
mentions 


Drug 
mention 
rate 2 


Drug 
intensity 
rate 3 




Number in 


Number in 




Number in 






Sex 


thousands 


thousands 


Percent 


thousands 


Rate per visit 


Both sexes 


9.551 4 


7,592 


79.5 


17,496 


1.83 


2.30 


Female 


5,683 


4,544 


80.0 


11,100 


1.95 


2.44 


Male 


3,868 


3,048 


78.8 


6,396 


1.65 


2.10 


Age 














Under 45 years 


1,473 


1,019 


69.2 


1,817 


1.23 


1.78 


45-64 years 


4,108 


3,138 


76.4 


7,030 


1.71 


2.24 


65 years and over 


3,971 


3,435 


86.5 


8,650 


2.18 


2.52 


Race 














White 


7,923 


6,226 


78.6 


14,545 


1.84 


2.34 


Black 


1,510 


1,290 


85.4 


2,774 


1.84 


2.15 


Problem status 














New problem 


871 


602 


69.2 


1,019 


1.17 


1.69 


Old problem 


8,680 


6,990 


80.5 


16,477 


1.90 


2.36 


Major reason for visit 














Acute problem 


1,087 


879 


80.9 


1,831 


1.68 


2.08 


Chronic problem, routine 


7,122 


5,660 


79.5 


12,962 


1.82 


2.29 


Chronic problem, flare-up 


805 


689 


85.5 


2,034 


2.53 


2.95 


Post surgery/post injury 


* 1 1 7 


*39 


*33.6 


*95 


*81 


*2.44 


Non-illness care 


419 


*324 


*77.3 


*574 


*1.37 


*1 .77 



'A visit in which one or more drugs were ordered or provided. 
2 Drug mentions divided by number of visits. 
3 Drug mentions divided by number of drug visits. 

"Includes races other than white and black not shown as separate categories. 

"Figure does not meet standards of reliability or precision (more than 30 percent relative standard error). 
Source: National Center for Health Statistics. Medication Therapy in Office Visits for Selected Diagnoses: The National Am- 
bulatory Medical Care Survey, United States, 1980. Vital and Health Statistics, Series 13, No. 71. DHHS Pub. No. (PHS) 
83-1732. Public Health Service. Washington, DC. U. S. Government Printing Office. January 1983, Table 5. p. 13. 



127 



Table 13 

Age-adjusted death rates for diabetes mellitus, by color and sex: selected years from 1950 to 
1980. 







Total 




White 






All other 




Year 


Both 






Both 




Both 








sexes 


Male 


Female 


sexes Male 


Female 


sexes 


Male 


Female 










Rate per 100,000 population 








1980 


10.1 


10.2 


10.0 


9.1 9.5 


8.7 


18.8 


16.4 


20.6 


1970 


14.1 


13.5 


14.4 


12.9 12.7 


12.8 


25.2 


20.4 


28.3 


1960 


13.6 


12.0 


15.0 


12.8 11.6 


13.7 


21.6 


16.1 


26.8 


1950 1 


14.3 


11.4 


17.1 


13.9 11.3 


16.4 


17.2 


11.8 


22.6 



For 1 950 and 1 960 rates are based on deaths assigned to category number 260 of the Sixth and Seventh Revisions of the Interna- 
tional Classification of Diseases. For 1970 and 1980, rates are based on deaths assigned to category number 250 of the Eighth 
and Ninth Revisions of the IDC 

1 Based on enumerated population adjusted for age bias in the population of races other than white. 

Source: 1) Department of Health, Education and Welfare: "Mortality Trends for Leading Causes of Death, U S. 1950-1969." Rockville, 
Maryland, Series 20, No. 16, Table K, p, 30 2) Department of Health, Education, and Welfare: Monthly Vital Statistics Report, Sum- 
mary Report, Final Mortality Statistics, 1970. Vol 22, No 8; 3) Advance Report, Final Mortality Statistics, 1980. Monthly Vital Statistics 
Report. Vol. 32. No 4, Supp DHHS Pub No (PHS) 83-1120 Public Health Service, Hyattsville, MD, August 1983. 



Table 14 

Diabetes mellitus deaths and rates (per 100,000 population) for Indians and Alaska Natives in reservation States and for the United 
States, all races and other than white populations, 1955-79. 



Number Crude Rates Age-Adjusted Rates and Their Ratio 



Indian to: 



Calendar 


Indian and 


U.S. 


Indian and 


U.S. 


Indian and 


U.S. 


U.S. Other 


U.S. 


U.S. Other 


Year 


Alaska Native 


All Races 


Alaska Native 


All Races 


Alaska Native 


All Races 


Than White 


All Races 


Than White 


1979 


170 


33,192 






22.8 


10.0 


18.5 


2.3 


1.2 


1978 


183 


33,841 


18.2 


15.5 


26.7 


10.4 


19.0 


2.6 


1.4 


1977 


161 


32,989 


18.3 


15.2 


24.6 


10.4 


19.5 


2.4 


1.3 


1976 


149 


34,508 


17.5 


16.1 


23.3 


11.1 


21.0 


2.1 


1.1 


1975 


145 


35,230 


17.4 


16.5 


23.8 


11.6 


21.7 


2.1 


1.1 


1974 


139 


37,329 


18.4 


17.7 


24.4 


12.5 


23.4 


2.0 


1.0 


1973 


157 


38,208 


19.7 


18.2 


28.4 


13.2 


25.3 


2.2 


1.1 


1972 


158 


38,674 


21.5 


18.6 


29.3 


13.6 


26.0 


2.2 


1.1 


1971 


166 


38,256 


21.5 


18.5 


31.7 


13.8 


27.5 


2.3 


1.2 


1970 


143 


38,324 


20.7 


18.9 


27.1 


14.1 


25.2 


1.9 


1.1 


1969 


127 


38,541 


20.1 


19.1 


21.1 


14.5 


27.7 


1.5 


0.8 


1968 


141 


38,352 


18.9 


19.2 


25.6 


14.7 


28.0 


1.7 


0.9 


1967 


107 


35,049 


18.9 


17.7 


23.3 


13.7 


24.5 


1.7 


1.0 


1966 


115 


34,597 


17.9 


17.7 


25.7 


13.9 


24.8 


1.8 


1.0 


1965 


110 


33,174 


17.6 


17.1 


25.4 


13.5 


23.6 


1.9 


1.1 


1964 


95 


32,279 


18.2 


16.9 


22.0 


13.5 


23.6 


1.6 


0.9 


1963 


115 


32,465 


17.6 


17.2 


29.9 


13.8 


23.1 


2.2 


1.3 


1962 


89 


31,222 


17.0 


16.8 


23.9 


13.5 


21.8 


1.8 


1.1 


1961 


70 


30,098 


14.8 


16.4 


19.6 


13.3 


21.0 


1.5 


0.9 


1960 


71 


29,971 


14.8 


16.7 


20.3 


13.6 


21.6 


1.5 


0.9 


1959 


82 


28,080 


14.8 


15.9 


26.1 


13.4 


19.4 


1.9 


1.3 


1958 


65 


27,501 


14.4 


15.9 


20.8 


13.0 


18.8 


1.6 


1.1 


1957 


62 


27,180 


14.3 


16.0 


19.6 


13.5 


18.2 


1.5 


1.1 


1956 


79 


26,184 


14.5 


15.7 


20.2 


13.0 


17.1 


1.6 


1,2 


1955 


64 


25,488 


14.6 


15.5 


17.0 


13.0 


16.5 


1.3 


1.0 



'Indian and Alaska Native crude rates are 3-year rates centered in the year specified. All other rates are based on single-year 
data. Estimated population methodology for the Indian and Alaska Native population revised for 1976. Maine, New York and 
Pennsylvania included as reservation states beginning in 1979. 

Source: Indian and Alaska Native— Indian Health Service. U.S. All Races and U. S Other than White— National Center for 
Health Statistics, Annual Mortality Publication, Vol. II, Part A (1955-1975) and Annual Advance Final Mortality Reports 
(1976-1979). Taken from FY 1984 Budget Appropriation Indian Health Service "Chart Series" Tables. Vital Events Branch, 
Office of Program Statistics, Division of Resource Coordination. Indian Health Service, Rockville, MD, April 1983. 



128 



Table 15 

Tuberculosis morbidity rates per 100,000 population. 



Calendar 


Indian and 




Alaska 


i J s 


U.S. 


U.S. 


Year 


Alaska Natives 


Indian 


Native 


All Races 


White 


All Other 


1981 


54.1 


50.9 


88.6 


11.9 


7.7 


37.6 


1980 


49.4 


47.1 


74.9 


12.3 


7.8 


39.4 


1979 


56.4 


51.9 


94.0 


12.6 


8.3 


39.6 


1978 


66.0 


62.8 


91.8 


13.1 


8.6 


41.6 


1977 


62.8 


58.2 


99.6 


13.9 


9.2 


44.8 


1976 


69.4 


59.2 


158.5 


15.0 


9.9 


48.0 


1975 


102.2 


102.4 


100.5 


15.9 


10.7 


50.9 


1974 


79.8 


74.5 


122.4 


14.4 


9.7 


45.1 


1973 


107.6 


102.4 


150.7 


14.8 


10.2 


46.3 


1972 


100.6 


94.3 


151.4 


15.8 


10.8 


50.3 


1971 


157.4 


152.0 


200.3 


17.1 


11.7 


53.8 


1970 


154.1 


154.1 


154.0 


18.3 


12.4 


59.0 


1969 


140.8 


141.6 


134.3 


19.1 


13.7 


59.7 


1968 


133.8 


128.0 


179.1 


21.3 


15.3 


65.1 


1967 


155.8 


152.7 


179.8 


23.0 


16.6 


70.2 


1966 


141.7 


127.8 


247.8 


24.4 


17.9 


71.9 


1965 


201.5 


160.5 


507.8 


25.3 


18.6 


74.9 


1964 


237.8 


184.1 


630.2 


26.6 


19.9 


76.5 


1963 


234.0 


192.3 


534.9 


28.7 


21.7 


81.5 


1962 


257.7 


209.4 


604.7 


28.9 


21 .9 


80.1 


1961 


318.8 


284.8 


562.8 


37.0 






1960 


322.4 


292.3 


547.5 


39.4 






1959 


418.0 


338.2 


1,048.0 


42.6 






1958 


485.0 


421.8 


978.7 


47.5 






1957 


565.2 


426.9 


1,649.7 


51.0 






1956 


680.6 


474.3 


2,283.8 


54.1 






1955 


758.1 


563.2 


2,325.7 


60.1 







Source: Tuberculosis Statistics, States and Cities, 1981 Pub. No 83-8249, Center tor Disease Control, Atlanta, GA, DHHS (to 
be published in 1983), and earlier reports in these series. Taken from FY 1984 Budget Appropriation Indian Health Service 
"Chart Series" Tables . Vital Events Branch, Office of Program Statistics, Division of Resource Coordination. Indian Health 
Service, Rockville, MD, April 1983. 



129 



Table 16 

Tuberculosis mortality, Indians and Alaska Natives in reservation States, United States, all races, and 
United States, other than white, 1955^79. (Rates per 100,000 population) 

Crude Rate 1 Age-Adjusted Rates 2 and their Ratio 



Ratio Indian and 





Indian and 






Indian and 






Alaska Native to: 


Calendar 


Alaska 




Alaska 


Alaska 


1 1 O 

U.S. 


1 1 O /~\4.L_ _ „ 

U.S. Other 


U.S. 


U.S. Other 


Year 


Native 


Indian 


Native 


Native 


All 1 — 

All Races 


than White 


All Races 


than White 


1979 


— 


— 


— 


4.4 


0.7 


2.5 


6.3 


1 .8 


1978 


4,2 


4.2 


3.4 


6.2 


1.0 


3.1 


6.2 


2.0 


1977 


5.1 


5.3 


3.0 


6.2 


1.0 


3.5 


6.2 


1 .8 


1976 


6.1 


6.3 


3.8 


8.5 


1.1 


3.8 


7.7 


2.2 


1975 


7.5 


7.5 


7.5 


9.9 


1.2 


4.0 


8.3 


2.5 


1974 


7.4 


7.3 


8.7 


9.8 


1.3 


4.6 


7.5 


2.1 


1973 


7.5 


7.3 


9.4 


9.1 


1.5 


5.2 


6.1 


1 .8 


1972 


7.3 


7.2 


7.7 


10.7 


1.7 


5.9 


6.3 


1 .8 


1971 


8.3 


8.2 


10.4 


10.6 


1.8 


6.6 


5.9 


1 .6 


1970 


9.7 


9.6 


11.2 


11.4 


2.2 


6.8 


5.2 


1 .7 


1969 


11.1 


11.0 


12.7 


16.1 


2.3 


8.0 


7.0 


2.0 


1968 


12.8 


12.8 


12.9 


16.5 


2.7 


9.4 


6.1 


1 .8 


1967 


13.5 


13.4 


14.3 


24.3 


3.0 


10.1 


8 1 


C . *-r 


1966 


15.3 


15.4 


15.3 


23.7 


3.4 


10.8 


7.0 


2.2 


1965 


19.0 


19.3 


16.0 


27.3 


3.6 


10.9 


7.6 


2.5 


1964 


21.8 


21.6 


24.0 


29.5 


3.8 


11.5 


7.8 


2.6 


1963 


25.1 


24.8 


28.5 


28.9 


4.3 


12.8 


6.7 


2.3 


1962 


26.0 


25.3 


34.0 


37.2 


4.5 


13.4 


8.3 


2.8 


1961 


25.4 


24.5 


34.8 


35.2 


4.8 


14.0 


7.3 


2.5 


1960 


26.6 


25.1 


43.1 


32.3 


5.4 


15.1 


6.0 


2.1 


1959 


29.0 


27.9 


41.8 


43.0 


5.8 


16.6 


7.4 


2.6 


1958 


34.3 


31.5 


65.1 


39.6 


6.5 


19.0 


6.1 


2.1 


1957 


38.2 


34.2 


83.3 


41.0 


7.1 


20.0 


5.8 


2.1 


1956 


46.2 


40.2 


116.8 


47.6 


7.7 


22.0 


6.2 


2.2 


1955 


55.8 


47.2 


157.5 


57.9 


8.4 


24.1 


6.9 


2.4 



1 Crude rates are 3-year averages centered in the year specified. 
2 Age-adjusted rates are for the single year specified. 

Note: Estimated population methodology revised in 1976. Maine. New York, and Pennsylvania included as reservation States begin- 
ning in 1979. 

Source: FY 1984 Budget Appropriation Indian Health Service "Chart Series" Tables. Vital Events Branch. Office of Program Statistics, 
Division of Resource Coordination. Indian Health Service, Rockville, MD, April 1983. 



130 



Table 17 

Percent of the population with limitation of activity due to chronic illness, by poor and nonpoor status, 
color, and age: United States, selected years 1964-81. 

(Data are based on household interviews of the civilian, nonmstitutionalized population.) 



Age and year 




Total 




White 


All other 


Poor 


Nonpoor 


Poor 


Nonpoor 


Poor Nonpoor 


All ages 




Percent of persons with limitation of activity 




1 964 


25.1 


P Q 

o.y 


9P n 

£O.U 


q n 
y .u 


1 P Q 

i o.y 


7.2 


1 Q79 

iy/o 


OR P. 


Q 7 


97 9 


Q Q 

y ,y 


9n £ 

ZU.O 


8.6 


-i nvc 

la/b 




1 U.D 


OP P 
ZOO 


1 n p 
I u.o 


9n 

ZU.O 


8.8 


1 fl7Q 

iy/o 


OC A 


10.9 


27.8 


11.0 


22.2 


9.5 


1 07D 

iy/» 


07 Q 

£ /.0 


11.5 


29.5 


11.8 


22.7 


9.7 


1 npn 

i you 


97 n 
eL 1 .U 


11.7 


28.2 


11.9 


23.4 


9.5 


1 QQ 1 

nyon 


OK R 

<;0.0 


1 1 .7 


28.4 


12.0 


21 .4 


10.0 


Under 17 years 














1964 


o -i 

3. 1 


o n 
£.U 


9 9 


9 n 
z.u 


9 7 


2.2 


1 Q79 

i y /o 


A 1 

4. I 


"5 9 


/I 9 


9 9 
o.£ 


9 P 
O.O 


3.0 


iy/o 


/I P 
4.0 


9 

o.o 


r^ n 

O.U 


9 K 
O.U 


A R 

4.0 


3.0 


i y / o 


O.^ 


3.7 


5.3 


3.8 


5.0 


3.6 


1 070 

i y /y 


a n 

4.y 


3.8 


5.7 


3.9 


3.8 


3.5 


i you 


0.4 


3.6 


6.0 


3.7 


4.3 


3.0 


HQQ1 

lytsi 


A A 

4.4 


3.6 


5.1 


3.7 


3.5 


3.3 


17-44 years 














1 964 


1 3.3 


7 9 


19/1 
1 0.4 


7 9 

/ .o 


19 1 
I o. I 


6.7 


1 Q7Q 

iy/o 


19 c; 
1 o.O 


7 /I 
/ .4 


1 9 P 
I £.0 


7 R 
I .O 


ic c 
1 O.O 


7.0 


1 Q7K 

i y/u 


19/1 

1 o.4 


7 7 


19 9 


7 7 


1 9 P 
I o.O 


7.6 


1 Q7Q 

ly/ts 


-I A 9 

1 4.Z 


7.5 


13.6 


7.5 


16.0 


6.7 


1 Q7Q 

i y /y 


1 A 9 
1 4.0 


7.9 


14.1 


8.0 


15.0 


7.1 


\ you 


1 A 1 

14.1 


7.7 


13.2 


7.7 


16.6 


7.4 


1 QQ 1 

lytsi 


1/17 


7.5 


14.6 


7.6 


14.8 


6.8 


45-64 years 














1 964 


36.7 


1 c n 
1 O.U 


97 A 
O / .4 


1^1 


9/1 R 
o4.0 


14.1 


1 Q79 

\i)f o 


A 9 O 

4o\£ 


1Q O 

1 0.*; 


/in 7 
4Z. / 


1 P 9 

1 0.£ 


/IC 1 

40. I 


18.2 


1 Q7K 

iy/o 


/in 7 

4o. / 


1 O. A 

i y.4 


/l 9 Q 

4^.0 


in c 

i y .o 


A 7 9 

4 / .0 


18.6 


1 Q7Q 

iy/o 


40.4 


1 9.7 


4^ 0 


19.6 


46.9 


21.6 


1 Q7Q 

i y / y 


4o.o 


20.0 


47.0 


20.0 


53.1 


20.3 


1 QQA 

i you 


Add 

4y.y 


20.2 


49.4 


20.3 


51.6 


19.2 


1 QQ 1 

i yts i 


cm .y 


20.5 


51.8 


20.2 


52.1 


23.0 


65 years and over 














1964 


55.2 


43.1 


54.2 


42.8 


63.0 


49.7 


1973 


49.1 


37.5 


47.8 


36.8 


59.5 


48.4 


1976 


50.2 


40.7 


49.4 


40.6 


55.6 


42.3 


1978 


50.7 


39.6 


49.3 


39.2 


60.9 


45.9 


1 979 


52.8 


41.7 


51.6 


41.3 


61.0 


48.8 


1980 


52.5 


41.3 


50.9 


41.1 


62.4 


44.6 


1981 


53.1 


4 1 6 


52.4 


41.2 


57.5 


48.4 



Note: Definitions of Poor and Nonpoor are based on family income: 





Poor 


Nonpoor 


1964 


under $3,000 


$3,000 and over 


1973 


under $6,000 


$6,000 and over 


1976 


under $7,000 


$7,000 and over 


1978 


under $7,000 


$7,000 and over 


1979 


under $7,000 


$7,000 and over 


1980 


under $7,000 


$7,000 and over 


1981 


under $7,000 


$7,000 and over 



Source: Unpublished data from the National Health Interview Survey, National Center for Health Statistics. Taken from Supplemen- 
tal Data from the Health Interview Survey, unpublished (1 983) to update earlier article: Wilson, Ronald W and White, Elijah L. "Changes 
in Morbidity, Disability, and Utilization Differentials between the Poor and Nonpoor": Data from Health Interview Survey: 1964 and 
1973. Medical Care, Vol. XV, No. 8. 636-646 August 1977. Table 11. 



131 



Table 18 

Selected indicators of morbidity for persons of Spanish ancestry by type of Spanish ancestry accord- 
ing to family income and age: United States, 1976-78. 



Persons of Spanish Ancestry 

Type of Spanish Ancestry 

Family income Mexican Puerto Other 

and age Total American Rican Cuban Spanish 

All Incomes 1 Incidence of acute conditions per 100 persons per year 

All ages 217.3 215.5 228.3 175.4 228.1 

Under 45 years ... 234.5 230.0 236.1 214.2 250.9 

45-64 years 144.5 140.0 205.3 94.4 148.0 

65 years and over . 128.4 143.1 100.0 140.4 103.6 

Number of restricted activity days per person per year 

All ages 17.4 15.6 24.4 16.5 17.6 

Under 45 years ... 14.0 12.7 19.6 13.1 13.8 

45-64 years 28.8 24.6 54.6 16.3 30.6 

65 years and over . 43.4 50.8 39.1 33.3 39.1 

Number of bed days per person per year 

All ages 7.9 6.9 12.1 8.3 7.8 

Under 45 years ... 6.7 5.8 10.1 7.4 6.6 

45-64 years 11.1 8.8 22.3 8.1 11.5 

65 years and over . 20.6 25.0 26.6 13.3 16.1 

Number of work-loss days per currently employed person per year 

All persons 17 

years or over .. . 5.5 5.1 7.4 4.2 5.9 

17-44 years 5.5 4.8 7.4 6.0 6.5 

45-64 years 5.1 6.0 7.9 1.4 3.6 

65 years and over . 7.6 8.6 0.0 2.9 10.4 

Percent of persons with chronic activity limitation 

All ages 9.9 8.3 14.7 12.3 10.2 

Under 17 years ... 3.0 2.4 5.7 3.3 2.8 

17-44 years 8.1 6.5 15.1 5.8 8.1 

45-64 years 23.1 21.5 32.9 16.7 24.8 

65 years and over . 45.6 48.4 57.1 40.4 39.3 

Percent of persons with "Fair" or "Poor" health perception 

All ages 13.1 12.5 18.9 12.6 11.2 

Under 17 years ... 6.3 5.6 10.0 4.7 5.9 

17-44 years 12.4 11.4 20.9 8.9 10.1 

45-64 years 27.4 29.1 38.6 16.7 23.2 

65 years and over . 35i3 44^3 28_6 31_7 25.7 



'Includes unknown income 

Source; "Using National Health Statistics for all Persons of Hispanic Ancestry as Surrogate Estimate for Persons of Specific Types 
of Ancestry: A preliminary Assessment of Problems of Bias." In Classification Issues in Measuring the Health Status of Minorities. 
U.S. Department of Health and Human Services, Public Health Service, Office of Health Research, Statistics, and Technology. Na- 
tional Center for Health Statistics. July 1980, Table 6. 



132 



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Arteriosclerosis of the Na- 
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Institute: Summary, Conclu- 
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June 1981. 

4. Levy, R.I.: "The Decline in 
Cardiovascular Disease Mor- 
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Reviews, Inc., Palo Alto, CA, 
1981. 

5. Wilder, OS.: "Prevalence 
of Selected Chronic Cir- 
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(HRA) 75-1521. U.S. Govern- 
ment Printing Office, 
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6. Cypress, B.K.: "Medica- 
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for Selected Diagnoses: The 
National Ambulatory Medical 
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Office, Washington, DC, 
January 1983. 

7. Koch, H.: "Drug Utilization 
in Office-Based Practice, a 
summary of findings, National 
Ambulatory Medical Care 
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Pub. No. (PHS) 83-1726. 
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Washington, DC, March 
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8. Unpublished data from 
the National Center for Health 
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Series 13. 

9. Kaupt, B.J.: "Utilization of 
Short-Stay Hospitals: Annual 
Summary." Vital and Health 
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82-1721. U.S. Government 
Printing Office, Washington, 
DC, December 1981. 

10. Health People: The 
Surgeon General's Report on 
Health Promotion and 
Disease Prevention 1979. 
U.S. Department of Health, 
Education, and Welfare, 
Public Health Service, DHEW 
(PHS) Pub. No. 79-55071. 
U.S. Government Printing Of- 
fice, Washington, DC, July 
1979. 

1 1 . Trends in Epidemiology: 
Application to Health Service 
Research and Training, ed. 
Gordan T. Stewart, Charles C. 
Thomas, Springfield, IL, 
1972. 

12. Public Health Service Im- 
plementation Plans for Attain- 
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tion, PHS 83-501 93A (USPS 
324-990), Public Health 
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September-October 1983 
issue. 

13. Cypress, B.K.: "Medica- 
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14. Rowland, M., and 
Roberts, J.: "Blood Pressure 
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Persons Ages 6-74 Years: 
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82- 1250, Advance Data 
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1982. 

15. Gordon, T., and Devine, 
B.: "Hypertension and 
Hypertensive Heart Disease 
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DHEW Pub. No. (HRA) 
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16. Roberts, J., and 
Rowland. M.: "Hypertension 
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Vital and Health Statistics, 
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17. Jackson, J. J.: "Urban 
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and London, England, 1981. 

18. Harlan, W.R., Hull, A.L., 
Schmouder, R.P., Thompson, 
F.E., Lacking, F.E., and 
Landis, J.R.: "Dietary Intake 
and Cardiovascular Risk Fac- 
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Correlates: United States, 
1971-75." Vital and Health 
Statistics, Series 11, No. 226. 
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83- 1676. U.S. Government 
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DC, February 1983. 

19. Rice, D.P., and 
Hodgson, T.A.: "Social and 
Economic Implications of 
Cancer in the United States." 
Vital and Health Statistics, 
Series 13, No. 20. DHHS 



Pub. No. (PHS) 81-1404. 
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Government Printing Office, 
Washington, DC, March 
1981. 

20. Young, J.L.: "Cancer in 
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Health Risks, and Social 
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No. 6. Summary of a Con- 
ference, ed. Parron, D.L., 
Solomon, F. and Jenkins, 
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Behavioral Medicine. National 
Academy Press, Washington, 
DC, 1982. 

21. Jams, R.F. and Parron, 

D. L.: "Cancer and Social 
Disadvantage." Summary of 
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Health Risks, and Social 
Disadvantage: Interim Report 
No. 6. Summary of a Con- 
ference, ed. Parron, D.L., 
Solomon, F. and Jenkins, 
CD.: Institute of Medicine. 
Division of Mental Health and 
Behavioral Medicine. National 
Academy Press, Washington, 
DC, 1982. 

22. Michaels, D.: "Minority 
Workers and Occupational 
Cancer: The Hidden Costs of 
Job Discrimination" In 
Behavior, Health Risks and 
Social Disadvantage: Interim 
Report No. 6. Summary of a 
Conference, ed. Parron, D.L., 
Solomon, F., and Jenkins, 
CD. Institute of Medicine. 
Division of Mental Health and 
Behavioral Medicine. National 
Academy Press, Washington, 
DC, 1982. 

23. Harris, M.: "The Public 
Health Impact of Diabetes" 
In Advances in Diabetes 
Epidemiology, ed. Eschwege, 

E. INSERM Symposium No. 
22. Institute National de la 
Sante et de la Recherche 
Medicale. Elsevier Biomedical 
Press, Amsterdam, New 
York, Oxford, 1982. 

24. Burton, L.E., Smith, H.H.. 
Nichols, A.W.: Public Health 
and Community Medicine, 
3rd Edition. Williams and 



133 



Wilkins, Baltimore/London, 
1980. 

25. Scott, G.: "Prevalence of 
Chronic Conditions of the 
Genitourinary, Nervous, En- 
docrine, Metabolic and Blood 
and Blood-forming Systems 
and of Other Selected 
Chronic Conditions, United 
States, 1973." Vital and 
Health Statistics, Series 10, 
No. 109. DHEW Pub. No. 
(HRA) 77-1536. U.S. Govern- 
ment Printing Office, 
Washington, DC, March 
1977. 

26. Bennet, P.H., Knowler, 
W.C., Pettitt, D.J., Carraher, 
M.J. and Vasquez, B.: 
"Longitudinal Studies of the 
Development of Diabetes in 
the Pima Indians" In Ad- 
vances in Diabetes 
Epidemiology, ed. Eschwege, 
E. INSERM Symposium No. 
22. Institute National de la 
Sante et de la Recherche 
Medicale. Elsevier Biomedical 
Press, Amsterdam, New 
York, Oxford, 1982. 

27. Zimmet, P., Taylor, R. 
and King, H.: "Diabetes in 
the Pacific— an 
Epidemiological Perspective" 
In Advances In Diabetes 
Epidemiology, ed. Eschwege, 
E. INSERM Symposium No. 
22. Institute National de la 
Sante et de la Racherche 
Medicale. Elsevier Biomedical 
Press, Amsterdam, New 
York, Oxford, 1982. 

28. Rudov, M.H., and 
Santangelo, N.: Health Status 
of Minorities and Low-Income 
Groups, U.S. Department of 
Health, Education and 
Welfare, DHEW Pub. No. 
(HRA) 79-627. Public Health 
Service, U.S. Government 
Printing Office, Washington, 
DC, 1979. 

29. Ventura, S.J., Taffel, 
S.M., and Spratley, E.: 
"Selected Vital and Health 
Statistics in Poverty and Non- 
poverty Areas of 19 large 
Cities, United States, 



1969-71." Vital and Health 
Statistics, Series 21 , No. 26. 
DHEW Pub. No. (HRA) 
76-1904. U.S. Government 
Printing Office, Washington, 
DC, November 1975. 

30. Wilder, OS.: "Limitation 
of Activity Due to Chronic 
Conditions, United States, 
1974." DHEW Pub. No. 
(HRA) 77-1537, Series 10, 
No. 111. U.S. Government 
Printing Office, Washington, 
DC, June 1977. 

31. Fingerhut, L.A. Wilson, 
R.W., and Feldman, J. J.: 
"Health and Disease in the 
United States" In Annual 
Review of Public Health, 
Vol. 1, 1980, ed. Breslow, L, 
Annual Reviews, Inc., Palo 
Alto, CA 1980. 



List of Tables 

1. Number and percent of 
deaths from the 15 leading 
causes of death by race, 
United States, 1980. 

2. Number and percent 
distribution of drug mentions 
by selected therapeutic 
categories, according to race 
and ethnicity of patient: 
United States, 1980. 

3. Number of discharges 
and average length of stay 
for patients discharged from 
short-stay hospitals, by 
selected first-listed diagnostic 
categories and color, United 
States, 1975 and 1981. 

4. Age-adjusted death rates 
for diseases of the heart, by 
color and sex: United States, 
selected years from 1 950 to 
1980. 

5. Average annual age- 
adjusted cancer of the colon 
incidence rates for males by 
race, SEER program, 
1973-1977. 

6. Average annual age- 
adjusted lung cancer in- 
cidence rates for males by 
race, SEER program, 
1973-1977. 

7. Prevalence rates of adults 
25-74 years with definite 
hypertension, by race, age, 
and sex: United States, 
1960-1962, 1971-1975, 
1976-1980. 

8. Prevalence rates of 
hypertension for persons 
25-74 years of age by treat- 
ment history, race, and sex 
with standard errors of the 
percent: United States, 
1960-1962, 1974-1975, and 
1976-1980. 

9. Age-adjusted death rates 
for malignant neoplasms, by 
color and sex: United States, 
selected years from 1 950 to 
1980. 

1 0. Death rates of selected 
cancer sites by sex and race, 
1970 and 1980. 

1 1 . Crude and age- 
standardized type II diabetes 



prevalence rates, United 
States, 1976. 

12. Number of office visits 
for diabetes mellitus, number 
and percent of drug visits, 
number of drug mentions, 
drug mention rate, and drug 
intensity rate, by selected 
characteristics: United States, 
1980. 

13. Age-adjusted death rates 
for diabetes mellitus, by color 
and sex: United States, for 
selected years from 1950 to 
1980. 

14. Diabetes mellitus deaths 
and rates per 100,000 
population for Indians and 
Alaska Natives in reservation 
States and for the United 
States, all races and other 
than white populations, 
1955-1979. 

15. Tuberculosis morbidity 
rates per 100,000 population. 

16. Tuberculosis mortality. In- 
dians and Alaska Natives in 
reservation States, United 
States, all races, and United 
States, other than whites, 
1955-1979. 

17. Percent of the population 
with limitation of activity due 
to chronic illness, by poor 
and nonpoor status, color, 
and age: United States, 
selected years 1964-1981. 

18. Selected indicators of 
morbidity for persons of 
Spanish ancestry by type of 
Spanish ancestry according 
to family income and age: 
United States, 1976-1978. 



134 



List of Figures 

1 . Average annual age- 
adjusted cancer incidence 
rates (all sites) for males by 
race, SEER program, 
1973-1977. 

2. Average annual age- 
adjusted cancer incidence 
rates (all sites) for females by 
race, SEER program, 
1973-1977. 

3. Age-adjusted mortality 
rates, all malignant 
neoplasms. 

4. Average annual age- 
adjusted cancer of the 
esophagus incidence rates 
for males by race, SEER pro- 
gram, 1973-1977. 

5. Average annual age- 
adjusted cancer of the colon 
incidence rates for males by 
race, SEER program, 
1973-1977. 

6. Average annual age- 
adjusted lung cancer in- 
cidence rates for males by 
race, SEER program, 
1973-1977. 

7. Average annual age- 
adjusted breast cancer in- 
cidence rates for females by 
race, SEER program, 
1973-1977. 

8. Average annual age- 
adjusted prostate cancer in- 
cidence rates for males by 
race, SEER program, 
1973-1977. 

9. Age-adjusted diabetes 
mellitus death rates. 

10. Tuberculosis cases in 
large cities, United States, 
1976. 



136 



Chapter VI 



Trauma: Accidents 
and Violence 



Table of Contents 

Overview 139 

A. Introduction 139 

B. Scope of the Problem 140 

C. Accidents 140 

1 . All Accidents 140 

2. Motor Vehicle Accidents 141 

3. All Other Accidents 143 

4. Fires 143 

5. Lead Poisoning in Children 144 

D. Violence 144 

E. Health Care Utilization for Trauma 146 
Tables 146 

References 154 
List of Tables 154 
List of Figures 154 



137 



138 



Chapter VI 



Trauma: Accidents 
and Violence 



Overview 

The relative impact of ac- 
cidents and violence on the 
disadvantaged in comparison 
with the general population is 
discussed below. White mor- 
tality data provide only a par- 
tial measure of the impact of 
these occurrences, the bulk 
of this analysis relies on mor- 
tality data, since current 
accident-related disability 
data with racial breakdowns 
are not available. 

The disparity between 
nonwhites and whites with 
regard to accidental death 
rates has decreased in the 
past 10 years. In 1970, the 
age-adjusted accident mor- 
tality rate of nonwhites was 
43 percent higher than that 
of whites. This differential 
dropped in 1980 to a rate 
among nonwhites that was 
only 19 percent higher than 
that of whites. Indians and 
Alaska Natives experience 
even higher accidental death 
rates, in comparison with the 
total population, than do all 
nonwhites. Death from ac- 
cidents is the second leading 
cause of death among In- 
dians and Alaska Natives, 
while it is the fourth leading 
cause of death for the total 
population. In 1979, the age- 
adjusted accident death rate 
of the Indian population was 
over three times that of the 
total population. 

While mortality from all 
types of accidents combined 
is higher for nonwhites than 
whites, the reverse is true 
with regard to motor vehicle 
accident mortality. As a 
percentage of all accidental 
deaths, deaths from motor 
vehicle accidents represent 
proportionately more deaths 
for the total population (50 
percent) than for nonwhites 
(40 percent) or for blacks (38 
percent). Among males, 



blacks had 50 percent more 
accidents (excluding motor 
vehicles) than whites in 1980, 
but 66 percent more in 1970. 
With regard to motor vehicle 
accident mortality, however, 
the rate among black males 
was 13.4 percent lower than 
the rate among white males 
in 1980. 

Death from fire is one of 
the types of "all other ac- 
cidental" deaths that occurs 
more freguently among non- 
whites than among whites. 
The Metropolitan Life In- 
surance Company reported a 
fire death rate among non- 
whites that was almost two 
and one-half times that of 
whites in 1976-1977. The dif- 
ferential was even greater in 
1968-1969, when nonwhites 
experienced almost three 
times the death rate from fire 
as did whites. 

Lead poisoning among 
children is of particular con- 
cern among the disadvan- 
taged because their blood 
lead levels are higher. The 
toxic properties of lead are 
made worse by iron defi- 
ciency and undernutrition, 
conditions that tend to occur 
more freguently among the 
disadvantaged. Although 
blood lead levels were about 
37 percent lower in 1980 
than in 1 976 for most 
segments of the population, 
the problem is still of con- 
cern. While only 2.0 percent 
of all white children 6 months 
to 5 years of age had 
elevated blood lead levels in 
1980, 12 percent of all black 
children had elevated levels. 

The racial differentials for 
homicide are higher than the 
racial differentials for any 
other cause of death. Black 
males have a homicide death 
rate over six times that of 
white males, and the 
homicide death rate of black 
females is four times that of 



white females. Due to a large 
increase in the homicide 
death rate among white 
males and a small decrease 
among black males, the ratio 
of black to white death rates 
from this cause decreased 
from 9.94 in 1970 to 6.1 1 in 
1980. 

Despite the racial dif- 
ferences in mortality from ac- 
cidents and violence, medical 
care utilization for trauma is 
guite similar for blacks and 
whites. Accidents, poison- 
ings, and violence were the 
reasons for 9.0 percent of all 
physician visits made by 
black patients and 7.3 per- 
cent of all visits made by the 
total population in 1976-1977. 
Hospitalization for trauma as 
a proportion of hospitalization 
for all causes was roughly 9 
percent for both whites and 
blacks in 1980 

A. Introduction 

This chapter focuses on the 
relative impact of various 
traumas on the disadvan- 
taged in comparison with the 
remainder of the population. 
The bulk of the comparison 
relies on mortality data that 
are routinely disaggregated 
by race. In addition, medical 
care utilization statistics, 
namely physician visits and 
hospitalizations, are 
employed to compare 
segments of the population. 
While available mortality data 
adeguately reflect the burden 
of accidental deaths on the 
disadvantaged compared 
with the total population, data 
on the freguency of nonfatal 
accidental injuries are not 
currently available, since 
injury rates by race were last 
published by the National 
Center for Health Statistics for 
the period 1965 to 1967. 



The mortality data 
analyzed in this chapter were 
obtained from three sources: 
the vital statistics system of 
the National Center for Health 
Statistics, the National Safety 
Council, and the Metropolitan 
Life Insurance Company. 
Disability data (not race 
specific) were obtained from 
National Safety Council 
publications. Data describing 
lead toxicity in children were 
obtained from the childhood 
lead poisoning surveillance 
program of the Center for 
Disease Control (CDC) and 
from the Second National 
Health and Nutrition Ex- 
amination Survey of the Na- 
tional Center for Health 
Statistics. 

A potentially outstanding 
source of accident and injury 
data is the National Electronic 
Injury Surveillance System, 
run by the Consumer Prod- 
uct Safety Commission. The 
Commission does not, 
however, disaggregate its 
data by any demographic 
variables that allow the types 
of analyses desired here. 
Thus, no data from this rich 
source have been included in 
this chapter. 

We have tried to in- 
vestigate accidents from all 
causes, including industrial or 
work-related accidents, which 
are of considerable impor- 
tance. Insurance companies 
cannot be deemed to have 
valid samples, and State 
Worker's Compensation 
bureaus and the Department 
of Labor's Bureau of Labor 
Statistics do not collect 
racial/ethnic data. Should 
such an analysis be con- 
sidered important, these 
sources should be en- 
couraged to add the perti- 
nent demographic variables 
to their data systems. 



139 



While the treatment of this 
subject area can be only as 
comprehensive as existing 
data, within this familiar con- 
straint several comparisons of 
the disadvantaged with the 
remainder of the population 
vis-a-vis accidents and 
violence are included in this 
chapter. 

Additional caveats in the 
interpretation of the data 
presented are contained in 
Chapter 1 of this book. In 
particular, material pertaining 
to revised death rates should 
be noted. 

B. Scope of the Problem 

"More than 153,000 
Americans die annually as a 
result of accidental injuries. . . 
It is estimated that in 1979, 
70 million people suffered 
nonfatal accidental injuries re- 
quiring medical treatment. In 
1980, the damage, injury, 
and lost productivity resulting 
from accidents cost the Na- 
tion an estimated $83.1 
billion." (1, p. 80) The Na- 
tional Safety Council 
estimates that an average of 
12 accidental deaths and 
1,160 disabling injuries occur 
every hour in the United 
States (2). In 1978, six motor 
vehicle accidental deaths, 
one accidental death at work, 
and three accidental deaths 
at home occurred per hour 
(2). The death and injury tolls 
from acts of violence are 
equally staggering. "Every 
hour in the United States 15 
or more people are stabbed, 
clubbed, or shot." (3, p. 581) 

In their very comprehen- 
sive treatment of public 
health and community 
medicine, Burton, Smith, and 
Nichols include a cogent and 
concerned appraisal of the 
problem of accidents in this 
country: 

This neglected 
epidemic of modern 
society is the nation's 



140 



most important en- 
vironmental health prob- 
lem and is the leading 
cause of death in the 
first half of life's 
span .... It is not only 
sad, but is a useless and 
tragic waste when young 
people's lives are 
needlessly and ruthlessly 
taken, or are perma- 
nently disabled due to 
accidents. The loss is not 
only to the individuals 
and their families but to 
the nation as well. These 
young people who other- 
wise could expect to live 
long and productive lives 
represent a loss of 
millions of productive 
man-years to our 
society .... For children 
aged one to 14 years, 
accidents claim more 
lives than the six leading 
diseases combined. For 
youths aged 15 to 24 
years, accidents take 
more lives than all other 
causes combined, and 
six and a half times 
more than the next 
leading cause in this age 
group. And this carnage 
continues. (4, p. 451) 
It is only in recent years that 
serious attention has been 
given to the problem of ac- 
cidents, especially to the 
problem of accident preven- 
tion. Part of the former inat- 
tention probably stemmed 
from a tendency to regard an 
accident as something due to 
chance and therefore beyond 
the control of the individual 
(3). The large life insurance 
companies have been 
credited with first giving at- 
tention to this problem by 
making efforts to reduce the 
extent of accidental injury or 
death. "As a result, some of 
the best health education 
work and promotion of home 
safety has been conducted 
by the larger insurance com- 
panies." (3, p. 674) Fire in- 
surance companies and other 



large industries, and finally 
public health workers, joined 
in the effort to develop safety 
guidelines and to reduce ac- 
cidents (3). In order to 
achieve noticeable reductions 
in the loss of life resulting 
from accidents and violence, 
efforts to prevent accidents 
must continue and attitudes 
must change. 

"A new type of attitude is 
needed. Each person must 
become convinced that most 
accidents result from such 
causes as poor judgement, 
alcohol, or thoughtlessness 
and that these can be either 
prevented or markedly cur- 
tailed ... .An aroused public 
and a concerted program 
could result in a decided 
reduction in this tragic and 
needless loss to our country 
and its people." (4, p. 449) 

C. Accidents 

This section opens with 
background material on how 
accidents are categorized by 
cause, location (home, work, 
etc.), and geographical loca- 
tion. Section C1 deals with 
the major group "all ac- 
cidents" combined. In Sec- 
tions C2, and C3, the subset 
"motor vehicle accidents" is 
discussed, followed by its 
complement, "all other ac- 
cidents." In Sections C4 and 
C5, two subsets of "all other 
accidents" are discussed. 

Accidents are conven- 
tionally grouped according to 
cause and place of occur- 
rence. Motor vehicle ac- 
cidents are typically the 
leading cause of accidental 
death and accounted for 
almost half (49.3 percent) of 
all accidental deaths in 1978. 
The percentage distribution 
of accidental deaths by 
cause in 1978 as reported in 
Accident Facts (2) appears 
below: 



Motor vehicle 


49.3 


[alio 


I Jx 


Drowning 


b.b 


Fires 


o.u 


Poisonings 




^bUIIUo allU Ml^UIUoJ 


o.o 


Qi iff or* Qti /~i n 
OUI lUL'CUIUl I 




(ingested object) 


2.8 


Firearms 


1.7 


Poisonings 




(gases and vapors) 


1.6 


Other 


15.5 




100.0 



Accidental deaths and in- 
juries are grouped according 
to place of occurrence in 
Figure 1. The percentage 
distribution by place of occur- 
rence shown below refers to 
accidental deaths but not to 
injuries: 



Place Percent 

Motor vehicle 49.3 

Work 12.4 

Home 22.0 

Public 20.6 



While accidents in motor 
vehicles accounted for the 
greatest number of deaths 
(51,500) in 1978, home ac- 
cidents resulted in the 
greatest number of disabling 
injuries (3.5 million) (see 
Figure 1). "The home, usual- 
ly considered a sanctuary, 
may not be as safe as 
formerly imagined. . . .Falls 
are the major cause of death, 
and fires are the next leading 
killer in home accidents. 
Every minute of the day, on 
the average, an American 
home is destroyed or damag- 
ed by fire." (4, pp. 449-450) 
Accidents vary by 
geographical location. 
"Although more injuries oc- 
cur in urban areas, more 
deaths occur in rural areas 
and in towns under 2,500 
population." (4, p. 449) 
1 . All Accidents 

Accidents are the fourth 
leading cause of death in the 
United States, accounting for 
5 percent of all deaths in 



Figure 1 

Accidental deaths and injuries in 1978. The death total in 1978 increased 
about 1,300 from 1977. Decreases in public and home deaths were offset by 
increases in motor-vehicle and work deaths. The death rate per 100,000 
population was 47.9, the third lowest rate on record. 

Temporary 

Type of Accident Disabling Permanemt Total Change 

Injuries Impairments Disabilities Deaths From 1977 

10,200,000* 360,000 9,800,000 104,500* + 1% 



Motor-Vehicle 2,000,000 150,000 1,850,000 51,500 -4% 

Public nonwork 1,800,000 46,900 

Work 200,000 4,400 

Home 10,000 200 





Work 

Nonmotor-vehicle 
Motor-vehicle 


2,200,000 

2,000,000 
200,000 


80,000 


2,100,000 


13,000 

8,600 
4,400 


+ 1% 


gK3 


Home 

Nonmotor-vehicle 
Motor-vehicle 


3,500,000 

3,500,000 
10,000 


90,000 


3,400,000 


23,000 

22,800 
200 


-1% 




Public 



2,700,000 



60,000 



2,600,000 



21,500 



-3% 



Source: NSC estimates (rounded) based on data from the National Center for Health 
Statistics, state industrial commissions, state traffic authorities, state departments 
of health, insurance companies, industrial establishments and other sources. Taken 
from National Safety Council. Accident Facts 1979 Edition, Chicago, IL 1979. Page 3. 



1980 (see Table 1, Chapter 
V). "Accident victims are not 
distributed evenly throughout 
the population. Teenagers 
and young adults have the 
highest motor vehicle death 
rate; fatal falls, which occur 
primarily in the home, 
disproportionately affect the 
population aged 75 and 
over; and children 10 years 
and younger are a high risk 
population for burns." (1, 
p. 80) 

The age-adjusted death 
rate from all accidents was 
close to 60 per 100,000 
population in the early 
1950's, decreased to almost 
50 in 1960, rose slightly to 
54 in 1970, then decreased 
to almost 40 in 1980. As 
shown in Table 1 , nonwhites 
had eight more accidental 
deaths per 100,000 popula- 
tion than whites in 1980 (49.5 



compared with 41.5). The 
nonwhite-to-white accident 
mortality ratio has decreased 
from 1.43 in 1970 to 1.19 in 
1980. Among males, a slight- 
ly greater reduction in the 
ratio of nonwhite-to-white ac- 
cident death rates occurred 
during this 10-year period. 
This ratio dropped from 1 .52 
in 1970 to 1.26 in 1980. 
Among females, the 
nonwhite-to-white accident 
mortality rate decreased from 
1.29 in 1970 to 1.16 in 1980. 

Accidents were the fourth 
leading cause of death in the 
total population in 1980, but 
they were the second leading 
cause of death among In- 
dians and Alaska Natives in 
1978. The age-adjusted acci- 
dent death rate exceeds the 
death rates from cancer and 
stroke in the Indian popula- 
tion (see Table 15, Chapter 
V). The accident death rate 



of Indian and Alaska Natives 
(140.7 deaths per 100,000 
population) was over three 
times the rate for the total 
population (43.7) in 1979. 
The ratio is even greater in 
the age group 25 to 34, in 
which Indians have over four 
and one-half times the acci- 
dent death rate of the total 
population (215.5 compared 
with 45.9 deaths per 100,000 
population) (see Table 2 and 
Figure 2). The ratio varies 
from about one and one-half 
to almost four and one-half 
times the total population in 
other age groups, and never 
drops below that of the total 
population. 

2. Motor Vehicle Accidents 

Motor vehicle accidents 
claimed 51,500 lives and 
resulted in 2 million disabling 
injuries in the United States in 
1978 (see Figure 1). As 



critical as the problem is in 
the United States, many 
European countries ex- 
perience far higher numbers 
of motor vehicle deaths per 
population (see Table 3). 
"When the motor vehicle 
hazard is appraised in 
several different ways, the 
fatality rates in the United 
States compare quite 
favorably with the rates of 
other countries." (5, p. 1 1) 

The category of motor 
vehicle accident deaths "in- 
cludes deaths involving 
mechanically or electrically 
powered highway transport 
vehicles in motion (except 
those on rails), both on and 
off the highway or street." (2, 
p. 42) It includes collisions of 
motor vehicles with other 
motor vehicles (motorcycles, 
buses, tractors), with fixed 
objects, and with pedestrians, 
railroad trains, pedal cyclists, 
and other collisions (animals, 
street cars), as well as non- 
collision motor vehicle ac- 
cidents (2). 

The three basic elements 
in the causation of 
automobile accidents are the 
vehicle, the environment, and 
the driver. While automobile 
construction and poor road 
design account for many traf- 
fic accidents, the majority (80 
percent) of all motor vehicle 
accidents are caused by the 
driver (4). From assorted 
studies of driver behavior 
and personality types, the 
following characteristics 
emerge. Drivers responsible 
for fatal accidents tended to 
be subject to more 
psychopathologic abnor- 
malities, social stress, acute 
personality disturbances, 
paranoid and suicidal tenden- 
cies, and depression than 
other drivers (4). Various 
health problems (arthritis, 
mental retardation, visual and 
sensory defects) and failure 



141 



to wear seat belts have also 
been found to contribute to 
automobile accident fatality 
(4). Excessive alcohol con- 
sumption is a known con- 
tributor to automobile acci- 
dent fatality. "At least 45 
percent of all fatal motor 
vehicle accidents are alcohol 
related; in single vehicle ac- 
cidents, 65 percent of drivers 
are legally drunk (i.e., with 
blood alcohol concentrations 
of over 0.10 percent)." (6, 
p. 45) Excessive alcohol con- 
sumption not only contributes 
to accidental death and injury 
among drivers and 
passengers but also among 
pedestrians. From study find- 
ings reported in 1976 (7, 
p. 14), a higher proportion of 
pedestrians injured in road 
accidents were found to have 
been drinking to excess. 

"Nationally, over 70 per- 
cent of automobile fatalities 
occur in rural areas." (4, 
p. 449) Part of the excess 
may be due to vacationers 
and other travelers through 
rural areas; however, a 
"more apparent reason for 
increased deaths in the rural 
areas is the discrepancy in 
adequate first aid at the acci- 
dent scene as well as 
delayed transportation to 
proper medical care 
facilities." (4, p. 449) One 
study of accident victims in a 
rural area demonstrated that 
23 percent of the cases had 
"died of injuries felt to be 
either definitely or possibly 
survivable." (4, p. 449) 

While death rates in 1978 
from all types of accidents 
grouped together were the 
leading cause of death in 
each 5-year age group from 
1 to 44 years, automobile ac- 
cidents alone were, in the 
same year, the leading cause 
of death for each 5-year age 
group from 1 to 25 years. In 
the 25- to 44-year age group, 
cancer and heart disease ac- 



Figure 2 

Age-adjusted accident death rates 

Per 100,000 
Population 



count for more deaths than 
automobile accidents alone, 
but deaths from all accidents 
combined are still greater in 
number than deaths from 
cancer and heart disease. (2, 
pp. 8-9) 

In 1980, the age-adjusted 
death rate for motor vehicle 
accidents was 22.9 per 
100,000 population, a rate 
only slightly lower than the 
1950 rate of 23.3 and 16.4 
percent lower than the 1970 
rate of 27.4 (see Table 4). 
Each race/sex group reflects 
the trends described above 
to varying degrees. Sex dif- 
ferences in motor vehicle ac- 
cident mortality are greater 
than race differences. 

The motor vehicle death 
rate was higher among black 
males in 1960 (5.4 percent 
higher) and in 1970 (13.3 
percent higher) than among 
white males (see Table 5). In 
the intervening years, 
however, a reversal of posi- 
tions occurred. By 1980, the 
motor vehicle accident death 
rate of black males (31.1 



I 



deaths per 100,000 popula- 
tion) was 13.4 percent lower 
than the rate for white males 
(35.9 deaths per 100,000 
population). 

No racial reversal occurred 
among females, but the racial 
trend was in the same direc- 
tion. Black females had con- 
sistently lower motor vehicle 
accident mortality rates than 
white females from 1960 
(13.4 percent lower) to 1980 
(35.2 percent lower) (see 
Table 5). Motor vehicle mor- 
tality is greater among males 
than females, and the sex 
disparity is greater among 
blacks than whites. In 1980, 
black males had three and 
three-quarters the death rate 
from this cause as had black 
females (31.1 deaths per 
100,000 population versus 
8.3), and almost three and 
one-third the rate in 1970 
(44.3 deaths versus 13.4). 
The ratio of motor vehicle 
deaths for white males to 
white females was 2.80 in 
1980 and 2.64 in 1970. 



Among Indians and 
Alaska Natives, accidental 
deaths were the second 
leading cause of death in 
1979 (see Table 15, Chapter 
V). The motor vehicle acci- 
dent death rate among this 
minority group (79.3 deaths 
per 100,000 population) (see 
Table 6) was three and one- 
third times the motor vehicle 
accident death rate of the 
total population (23.7 deaths 
per 100,000 population) in 
the same year. This 
represents a slight improve- 
ment during the years since 
1969, when the Indian 
population motor vehicle ac- 
cident death rate was almost 
three and one-half times that 
of the total population (99.1 
versus 28.5). 

We cannot be sure of the 
specific trait that places this 
minority group at higher risk 
for motor vehicle deaths. It is 
likely, however, that one 
cause of traffic accidents, 
drunken driving, may be a 
heavy contributor to ac- 
cidents in this minority group, 
which is known to have a 
high prevalence of alcoholism 
(8). Another contributor may 
be proportionately more rural 
driving (on reservations) at 
higher speeds, and driving 
off-road terrains. 

This discussion of motor 
vehicle accidents will con- 
clude on a positive note: 
motor vehicle deaths and 
death rates are decreasing. 
The number of motor vehicle 
accident deaths was 51 ,091 
in 1980; the number dropped 
to 49,301 in 1981, then drop- 
ped precipitously to 43,947 
in 1982, and dropped slightly 
to 43,028 in 1983 (9). 

Experts at the National 
Highway Traffic Safety Ad- 
ministration and at the In- 
surance Institute for Highway 
Safety were especially puz- 
zled by the large drop from 
1981 to 1982 (10). Such ex- 
planations as: (a) the 
downturn in the economy in 



250 



200 



150 



100 



50 



0 




Source: FY 1984 Budget Appropriation Indian Health Service "Chart Series". Vital 
Events Branch, Office of Program Statistics, Division of Resource Coordination. Indian 
Health Service, Rockville, MD, April, 1983. 



142 



1982 (with the accompanying 
unemployment) resulting in 
decreased vehicle usage; 
(b) increased seat belt usage 
and other safety measures; 
and (c) the anti-drunk driving 
campaign were felt to be in- 
adequate to explain this 
magnitude of change (10). 

Perhaps a combination of 
proportionately greater 
numbers of smaller cars, 
more expensive cars (car 
prices soared in 1982), along 
with the downturn in the 
economy produced a 
cautious mindset in the ma- 
jority of the population which 
had a spillover effect into 
more cautious driving pat- 
terns. The population age 
shift, resulting in fewer per- 
sons in the high-risk age 
group, may have also con- 
tributed to this effect. 
3. All Other Accidents 
Published accident mortality 
data are commonly classified 
into two broad categories: 
deaths resulting from motor 
vehicle accidents, and deaths 
resulting from all other ac- 
cidents. While motor vehicle 
accidental deaths constitute 
roughly 50 percent of all ac- 
cidental deaths for the total 
population as well as for the 
white population, they repre- 
sent a far lower percentage 
of all accidental deaths 
among the nonwhite and 
black subpopulations (40.5 
and 37.7 percent, respec- 
tively). The percentages of 
accidental deaths falling into 
these two categories by race 
were calculated from 1980 
data (11, p. 27) and are 
shown below; 



All Races 

Motor vehicle 50.3 
All other 49.7 
All accidents 100.0 



As discussed in the 
previous section, motor vehi- 
cle accident deaths for black 
males in 1980 were lower 
than for white males. They 
were not lower by a factor 
that would have resulted in 
the above differences, 
however. Therefore the pro- 
portional variations depicted 
in the above data are due 
both to blacks having lower 
motor vehicle accidental 
death rates, and to elevations 
in their death rates from other 
kinds of accidents. By in- 
spection, and from the data 
that follow, it appears that the 
effect of nonautomobile 
deaths is the stronger of the 
two effects. 

The age-adjusted death 
rate for all other types of ac- 
cidents among nonwhites 
(29.3 deaths per 100,000 
population) was 63 percent 
higher than that for whites 
(18.0) in 1980 (11, p. 33). 
Death rates for all other types 
of accidents by race and sex 
are presented in Table 5. 
Among males, blacks had a 
rate slightly over one and 
one-half times that of whites 
in 1980 (46.0 deaths per 
100,000 population for blacks 
versus 30.4 for whites). The 
differential was greater in 
1970 (1.66) due to a larger 
decrease in death rates 
among blacks than whites 
between 1970 and 1980. The 
racial differential among 
females, however, increased 
between 1970 and 1980 
because of the larger 
decrease in rates among 
white females than among 
black females. The causes of 



All Other Races 
White Total Black 

52.0 40.5 37.7 

48.0 59.5 62.3 

100.0 100.0 100.0 



all other accidental deaths 
(excluding motor vehicle 
deaths) are listed below, 
along with the percentage for 
each type in the total popula- 
tion in 1978 (2). 



Falls 


26.0 


Drowning 


13.0 


Fires 


11.9 


Poisonings 




(solids, liquids) 


6.4 


Suffocation 




(ingested object) 


5.5 


Firearms 


3.4 


Poisonings 




(gases, vapors) 


3.2 


Other* 


30.6 




100.6 



'Mechanical suffocation, struck by 
falling objects, electric current, air and 
railway transport, medical complica- 
tions, and others. 



The racial distribution of 
deaths from the three leading 
causes of other accidental 
deaths in 1978 were: 
falls— 90.6 percent white ver- 
sus 9.4 percent nonwhite; 
drowning— 75.7 percent 
white versus 24.3 percent 
nonwhite; fires— 71.2 percent 
white versus 28.8 percent 
nonwhite. (12, Table, 4-5) 
Thus, compared with the 
population distribution (83 
percent white versus 1 7 per- 
cent nonwhite), nonwhites 
had proportionately more ac- 
cidental deaths from drown- 
ing and fires and propor- 
tionately fewer deaths from 
falls than did whites. 

Deaths from fire are dis- 
cussed below. Data related 
to lead poisoning in children 
are discussed in Part 5. 
4. Fires 

"Each year. . .(fires) result in 
about 6,500 deaths, more 
than 325,000 injuries and 
nearly $4.5 billion in property 
loss." (13, p. 5) Death from 
fires was the fourth leading 
cause of accidental death in 
1 978 (after traffic deaths, 
falls, and drowning). 
Although the number of lives 



claimed by fire are a fraction 
of those claimed by traffic 
deaths (6,163 versus 52,144 
in 1978) (12), death from fire 
occurs more frequently 
among nonwhites than 
among whites. Based on 
data from the Metropolitan 
Life Insurance Company, the 
mortality rate from fires 
among nonwhites was found 
to be almost two and one- 
half times the rate among 
whites (6.0 deaths per 
100,000 population versus 
2.5 deaths per 100,000 
population) (see Table 7). 

Death from fire decreased 
between the two time periods 
1968-1969 and 1976-1977 
(see Table 8). The percent- 
age decreases in death rates 
from fires between the earlier 
and later periods were 13.8 
for whites and 29.4 for non- 
whites. The greater decrease 
among nonwhites compared 
with whites during this time 
period produced a nonwhite- 
to-white fire death rate ratio 
in 1976-1977 (2.40) that was 
lower than that in 1968-1969 
(2.93). 

Other information regard- 
ing fires includes the follow- 
ing: Males and both the very 
young and the elderly ex- 
perience higher death rates 
from fires than do females 
and the adolescent and 
middle-aged segments of 
population. "The most com- 
mon fatal accidents to 
children at home were from 
fires (36 percent)." (6, p. 45) 
Mortality due to fires in- 
creases with the onset of 
cold weather, with peak mor- 
tality occurring in January. 
(14, p. 6) Almost 87.6 per- 
cent of fires take place in 
residences (12). Geographi- 
cally, the South and South- 
west report the highest death 
rates from fires (14). The 
three leading causes of fires 
in 1970-1971 were (a) faulty 
wiring, or misuse of and 



143 



Figure 3 

Mean blood lead levels (PbB) of children ages 6 months-5 years in large 
urban areas: United States, 1976-80 

White 

§||§ Black Mean PbB(,«g/dl) 

95% confidence intervals 



0 


8 


12 


16 


20 


24 


28 


Central 






I 


1 






city 








I 


1 
















Non-central 






h 


1 






city 








r— 


i 



















Source: National Health and Nutrition Examination Survey, National Center for 
Health Statistics. Taken from National Center for Health Statistics: Blood lead levels 
for persons 6 months-74 years of age: United States 1976-80. Advance Data From 
Vital and Health Statistics, No. 79. DHHS Pub. No. (PHS) 82-1250. Public Health 
Service. Hyattsville, MD, May 12, 1982. 



defects in electrical ap- 
pliances and equipment; 
(b) defective or overheated 
heating and cooking equip- 
ment; and (c) poor smoking 
habits and the careless use 
of matches. (14, p. 8) 
5. Lead Poisoning in 

Children 
Although lead poisoning may 
be considered a chronic 
disease, it is classified by the 
International Classification of 
Diseases (15) among ac- 
cidents and thus will be in- 
cluded here. Exposure to 
lead is a serious health prob- 
lem among children (16, 
p. 16). In fact, one national 
goal listed in Promoting 
Health/Preventing Disease: 
Public Health Implementation 
Plans for Attaining the Objec- 
tives of the Nation is the 
reduction of the lead toxicity 
level in children from the cur- 
rent prevalence of 4,000 per 
100,000 population to 500 
per 100,000 population by 
1990 (1, p. 56). 

The Center for Disease 
Control provides data about 
lead toxicity in children based 
on roughly 60 federally fund- 
ed screening projects in 25 
states (16). "In 1980, 
502,900 children were 
reported to have been 
screened, and 26,500 were 
identified with lead toxicity." 
(17, p. 133) In addition, in 
the first half of 1981, "almost 
20,000 children were under 
pediatric management for 
lead toxicity." (18, p. 438) 

Air, food, dust, dirt, soil, 
water, and lead-based paint 
are the most common 
sources of environmental 
lead for young children (16, 
p. 5). " . . . Because of higher 
metabolic rates and greater 
physical activity of children, it 
is estimated that under com- 
parable exposure, children in- 
hale two to three times more 
airborne lead per unit of 
body weight than adults do. 



Even at relatively low levels 
of lead, subclinical effects of 
lead exposure in children, in- 
cluding impaired 
hematopoiesis and neuro- 
psychologic deficits, have 
been reported in the 
literature." (16, p. 5) Elevated 
blood lead levels in children 
are of particular concern 
"because of the vulnerability 
of the developing nervous 
system to lead," (19, p. 10). 

The CDC surveillance pro- 
gram deals with selected 
locations and individuals who 
are potentially at high risk of 
exposure (16). Measurements 
of lead exposure by means 
of blood lead level from the 
Second Health and Nutrition 
Examination Survey 
(NHANES II), on the other 
hand, are based on a prob- 
ability sample representative 
of the U.S. population (16). 
The CDC guideline for 
elevated blood lead levels is 
30 micrograms or more per 
deciliter of whole blood, used 
by CDC for referring children 
for followup (16). An 
estimated 4.0 percent, or ap- 
proximately 675,000 children 
6 months to 5 years of age, 
have elevated blood lead 
levels (16, p. 12). 

Mean blood lead levels 
are higher for blacks of all 
ages than for whites, but are 
appreciably higher among 
black children 6 months to 5 
years of age (micrograms) 
than among white children of 
the same age (14.9 
micrograms) (see Table 9). In 
addition, while only 2.0 per- 
cent of all white children 6 
months to 5 years of age 
have blood lead levels of 30 
micrograms or more, 12.2 
percent of all black children 
have blood lead levels of this 
magnitude (see Table 9). 

The toxic properties of 
lead are made worse by iron 
deficiency and undernutrition 
(19, p. 10). Because these 
conditions tend to occur 



more frequently in black 
children than white children, 
high blood lead levels among 
black children have even 
more severe consequences. 
Higher blood lead levels are 
found among children living 
in low income households 
and inner cities of large ur- 
ban areas, as shown in 
Figures 3 and 4. At each in- 
come level in both central 
cities and noncentral cities, 
black children have higher 
blood lead levels than white 
children. 

In the 4-year period be- 
tween February 1976 and 
February 1980 (the period of 
NHANES II), a 36.7 percent 
reduction in the overall mean 
blood lead level was found 
among all races, ages, and 
both sexes (16). Part of the 
reduction is attributable to 
reductions of lead levels in 
the environment. "The most 
discernible change in en- 
vironmental lead sources was 
the reduced use of lead in 
gasoline ..." (17, p. 133) 

"Although the decrease in 
mean blood lead levels was 
dramatic, the problem of 
pediatric lead poisoning in 
the United States has not 



been solved." (17, p. 133) 
Lead poisoning in children 
remains a public health prob- 
lem, particularly among the 
disadvantaged. 
D. Violence 

"Every hour in the United 
States 1 5 or more people are 
stabbed, clubbed, or 
shot. . . .The statistical chance 
of an American being 
murdered in any one year is 
almost 1 in 20,000." (3, 
p. 581) 

Our attention in this 
chapter will be limited to 
domestic violence, and within 
that limitation, to crimes 
which result in death or in- 
jury. Thus we will be discuss- 
ing homicide, suicide, rape, 
aggravated assault, and rob- 
bery with injury. Before 
discussing the relative impact 
of homicide on specified 
segments of the population, a 
few definitions are in order. 
"Practically speaking, 
homicide includes any violent 
death that is neither a suicide 
nor an accident .... 
Homicides . . .may be con- 
sidered to fall into three 
categories. ..." (3, p. 582) 



144 



Figure 4 

High blood lead levels in children 6 months-5 years of age, according to 
annual family income and race: United States, average annual 1976-80 

White 

Percent with high blood lead levels 



Black 



Less than 
$6,000 



$6,000- 
$14,999 



$15,000 
or more 



10 



15 




20 



Source: National Center for Health Statistics: Division of Health Examination 
Statistics. Taken from National Center for Health Statistics: Health United States, 
1982. DHHS Pub. No. (PHS) 83-1232. Public Health Service. Washington. U.S. 
Government Printing Office, December 1982. Figure 3, p. 11. 



The first category may be 
described as "planned killing 
that is consciously acceptable 
to the perpetrator at the 
time." (3, p. 582) This is 
commonly referred to as 
premeditated murder. It 
represents, however, only a 
small fraction of all 
homicides. The second type 
of homicide occurs as an 
emotional response, not con- 
sciously planned, to a conflict 
that may have extended over 
a period of time. The third 
type of homicide is commit- 
ted as an act of self-defense 
by a law enforcement officer 
or an individual. About 80 
percent of all homicides 
belong to the second 
category (3). Roughly 65 per- 
cent of all homicides of the 
first and second types occur 
among persons who know 
each other (3). 

The risk of homicide 
varies dramatically among 
segments of the population. 
Age-specific homicide rates 
expressed as deaths per 
100,000 population were 
highest among persons 15 to 
24 years of age (15.6), 25 to 



34 years of age (19.6), and 

35 to 44 years of age (15.1) 
in 1980 (11, p. 18). The 
homicide rate in these age 
groups, especially among 
persons 25 to 34 years of 
age (a rate of 19.6), is almost 
twice the rate of the total 
population, 10.7 

The racial differentials for 
homicide are higher than the 
racial differentials for any 
other cause of death. The 
ratio of black to white age- 
adjusted death rates for all 
causes of death was 1.50 in 
1980, compared with a ratio 
of 5.88 for deaths from 
homicide and legal interven- 
tion (see Table 16, Chapter 
II). The ratio is even higher 
among males. In 1980, black 
males had a homicide rate of 
66.6 per 100,000 population, 
while the white male rate was 
10.9, a ratio of 6.1 1 (see 
7ab/e 5). Black females, with 
a rate of 13.5 homicide 
deaths per 100,000 popula- 
tion, are over four times more 
likely to die as a result of 
homicide than white females, 
whose death rate from this 



cause is 3.2 per 100,000 
population. Due to a slight 
decrease of 1 .5 percent in 
the homicide rate among 
black males since 1970 and 
a large increase in the homi- 
cide rate among white males 
(60.3 percent), the ratio of 
black-to-white death rates 
from this cause among males 
decreased from 9.94 in 1970 
to 6.11 in 1980. 

Among females, the ratio 
also decreased, from 6.33 in 
1970 to 4.22 in 1980, due to 
the larger increase in deaths 
from this source among white 
females (52.4 percent) than 
among black females (1.5 
percent). 

Indians and Alaska 
Natives also have experi- 
enced disproportionately 
higher homicide rates than 
the population as a whole. In 
1979, the Indian age- 
adjusted death rate from this 
cause was almost two and 
one-half times that for the 
total population (25.5 com- 
pared with 10.4 deaths per 
100,000 population), but it 
was 29.2 percent lower than 
the rate for races other than 
white (36.0) (see Table 10). 

Suicide has been a male- 
dominated and white- 
dominated form of violence. 
The ratio of male to female 
suicide has been approx- 
imately 3 to 1 among whites 
and approximately 4 to 1 



among blacks (see Table 5). 
Among females, the rates in- 
creased after 1960 but seem 
to have stabilized since 1970. 
The rates among males have 
increased steadily throughout 
the same two-decade period, 
but the rise has been much 
sharper among black males. 
The result is that the white-to- 
black female ratio has been 
steady at about 2% to 1 . 
Among males, the white-to- 
black ratio has been drop- 
ping from under 3 to 1 to 
under 2 to 1 . 

The recent history of 
crimes with victims is sum- 
marized below. Blacks have 
for many years had higher 
crime victim rates than have 
whites. In the 5-year period 
from 1975 to 1980, however, 
it appears that their victim 
rates were decreasing and 
are starting to approach 
those of whites. This is pro- 
bably due in part to the 
decrease in black rates. At 
the beginning of this 5-year 
period the black-to-white ratio 
for all crimes was 1.39, and 
that ratio decreased to 1 .25 
by the period's end. The 
rape rates were equal and 
relatively constant throughout 
that period. The robbery with 
injury rates went from a 
black-to-white ratio of 2.5 to 
2.0, and the aggravated 
assault ratio decreased from 
1.56 to 1.33. 



Criminal Violence (20, p. 177) Rates per 1,000 persons 

1975 1979 1980 

White Black White Black White Black 

Rape 11 12 11 
Robbery 

with injury 2 5 2 4 2 4 
Aggravated 

assault 9 14 9 13 9 12 

Total 31 43 34 42 32 40 



145 



E. Health Care Utilization 
for Trauma 

Thus far, the impact of ac- 
cidents and violence on the 
disadvantaged has been 
measured by deaths from 
these causes. Measurement 
of the relative impact of non- 
fatal accidents and violence 
is made difficult by the pau- 
city of published data by 
race in this area. In lieu of 
prevalence data, two 
measures of medical care 
utilization are employed, 
namely physician visits and 
hospitalizations. These are far 
from ideal surrogate meas- 
ures of prevalence of illness 
and disability resulting from 
accidents and violence. Most 
notably, comparisons among 
the disadvantaged and the 
remainder of the population 
tend to be distorted due to 
the tendency among 
members of lower 
socioeconomic levels to use 
health care facilities less than 
other groups. 

In Table 1 1 , physician 
visits for 1975-1976 are 
presented by major 
diagnostic groups and by 
race. For the combined 
category "accidents, poison- 
ings, and violence," black 
patients had a slightly higher 
percentage of all visits (9.0 
percent) than all patients (7.3 
percent). 

Hospitalizations for ac- 
cidents, poisonings, and 
violence combined and for 
selected types of injuries are 
presented in Table 12 by 
race for 1971 and 1981. 
Hospitalizations for accidents, 
poisonings, and violence are 
very similar for each race for 
both 1971 (10.3 and 10.5 
percent, respectively) and 
1981 (9.3 and 9.7 percent) 
(see Table 12). 



Table 1 

Age-adjusted death rates for accidents, by color and sex: United States, selected years from 1950 to 
1980 1 . 







Total 






White 






All Other 






Both 






Both 






Both 






Year 


Sexes 


Male 


Female 


Sexes 


Male 


Female 


Sexes 


Male 


Female 


1980 


42.3 


64.0 


21.8 


41.5 


62.3 


21.4 


49.5 


78.4 


24.8 


1970 


53.7 


80.7 


28.2 


51.0 


76.2 


27.2 


72.8 


115.7 


35.1 


1960 


49.9 


73.9 


26.8 


47.6 


70.6 


25.4 


67.3 


101.1 


36.1 


1950 


57.5 


83.7 


31.7 


55.6 


81.0 


30.6 


72.0 


107.1 


38.8 



'1950 and 1980 data are based on the Sixth and Seventh Revisions of the ICD respectively. 1970 and 1980 data are based on 
the Eighth and Ninth Revisons respectively 

Source: Compiled by CHESS from 1) Department of Health, Education, and Welfare: "Mortality Trends for Leading Causes of Death, 
U.S. 1950-69." Rockville, Maryland, Series 20, No. 16, Table K, p. 30. And 2) National Center for Health Statistics: Advance report, 
final mortality statistics, 1980. Monthly Vital Statistics Report, Vol. 32, No. 4 Supp. DHHS Pub. No. (PHS) 83-1120. Public Health 
Service, Hyattsville, MD. August 1983 



Table 2 

Age-specific accident death rates (Rates per 100,000 population). 

Ratio of Indians 

Indian and Alaska Natives U.S. All Races and Alaska Natives 



Age at Death 


CY 1977-79 


1 


CY 1978 




to U.S. All Races 


Number 


Rate 


Number 


Rate 


Rate 


Under 1 


56 


78.5 


1,262 


39.4 


2.0 


1-4 


219 


76.8 


3,504 


28.8 


2.7 


5-14 


244 


31.5 


6,118 


17.2 


1.8 


15-24 


1,175 


211.7 


26,622 


64.5 


3.3 


25-34 


748 


215.5 


15,533 


45.9 


4.7 


35-44 


452 


167.7 


9,491 


39.0 


4.3 


45-54 


329 


154.1 


9,174 


39.6 


3.9 


55-64 


253 


162.3 


9,600 


46.4 


3.5 


65-74 


149 


152.2 


9,072 


60.7 


2.5 


75-84 


92 


229.4 


8,956 


129.4 


1.8 


85 + 


57 


435.0 


6,107 


276 8 


1.6 



'Maine, New York and Pennsylvania included as reservation States beginning in 1979. 

Source: FY 1984 Budget Appropriation Indian Health Service "Chart Series" Tables. Vital Events Branch, Office of Program Statistics, 
Division of Resource Coordination. Indian Health Service, Rockville, MD, April 1982 



146 



Table 3 

Mortality from motor vehicle accidents, selected countries, 1965-66 and 1975-76 



Number of 
Motor Vehicles 
per 1 ,000 Population 



Country 



1965-66 



1975-76 



Average Annual Death Rate 



Per 100,000 Population 



Per 100,000 Registered 
Motor Vehicles 



1965-66 



1975-76 



1965-66 



1975-76 



United States 


482 


655 


26.3 


21.7 


54.5 


33.0 


New Zealand 


361 


516 


20.9 


20.5$ 


58.0 


39.9$ 


Canada 


346 


505 


26.4 


24.1 


76.1 


47.7 


Australia 


342 


493 


27.9 


27.4$ 


81.7 


56.9$ 


France 


351 


466 


24.8 


25.5 


70.9 


54.8 


Netherlands 


285 


411 


20.6 


17.4 


72.5 


42.3 


West Germany* . . 


. 219 


354 


27.5 


24.1$ 


125.2 


68.1 


Denmark 


343 


345 


21.3 


16.8 


62.1 


49.8 


Finland 


233 


340 


23.2 


19.3$ 


99.7 


57.6$ 


Japan 


159 


339 


14.2 


9.2 


89.7 


27.1 


Norway 


218 


316 


11.7 


12.6 


53.3 


39.8 


Great Britain t 


228 


303 


14.6 


11.6 


64.2 


38.0 


Italy 


. 206 


291$ 


17.3 


17.0$ 


84.3 


58.5$ 



'Includes West Berlin 

tlncludes England and Wales, Northern Ireland, and Scotland. 
+ 1975 only. 

Note: Ranked according to number of motor vehicles per 1,000 population in 1975-76 

Source of basic data: World Road Statistics 1972-76, 1977 Edition. International Road Federation, Geneva. Switzerland; 7978 
Demographic Yearbook, United Nations; various reports of the National Center for Health Statistics, Statistics Canada. National 
Safety Council, and Motor Vehicle Manufacturers Association. Taken from Metropolitan Life Insurance Company. Statistical Bulletin 
Vol 60, No 2, April-June 1979, p 9. 



Table 4 

Age-adjusted death rates for motor vehicle accidents, by color and sex: United States, selected years 
from 1950 to 1980. 

Total White All Other 

Both Both Both 

Year Sexes Male Female Sexes Male Female Sexes Male Female 



1980 


22.9 


34.3 


11.8 


23.4 


34.8 


12.3 


20.3 


32.9 


9.4 


1970 


27.4 


41.1 


14.4 


26.9 


40.1 


14.4 


30.9 


49.7 


14.3 


1960 


22.5 


34.5 


11.0 


22.3 


34.0 


11.1 


24.4 


39.5 


10.6 


1950 


23.3 


36.4 


10.7 


23.1 


35.9 


10.6 


25.7 


41.2 


11.1 



Note: Intercensal years' rates in this table have not been revised to reflect new population estimates that incorporate census years data. 
Source: Department of Health, Education, and Welfare: "Mortality Trends for Leading Causes of Death. U.S. 1950-69." Rockville. 
Maryland. Series 20, No 16, Table K, p. 30. And National Center for Health Statistics: Advance report, final mortality statistics, 
1980. Monthly Vital Statistics Report, Vol. 32, No. 4 Supp. DHHS Pub No (PHS) 83-1 120. Public Health Service. Hyattsville, MD. 
August 1983. 



147 



Table 5 

Death rates from accidents and violence: 1960 to 1980. 

(Deaths per 100,000 population. Beginning 1970, exlcudes deaths of nonresidents or the U.S. Deaths for 1979 classified according 
to the Ninth Revision of the International Classification of Diseases, for earlier years classified according to the revision in use at the time. 

White Black 



Sex, cause of 

death, and age 1960 1970 1975 1978 1979 1980 1960 1970 1975 1978 1979 1980 



Male 
Motor vehicle 

accidents 31.5 39.1 32.2 36.2 37.3 35.9 33.2 44.3 32.7 32.7 32.0 31.1 

All other accidents . 38.6 38.2 35.5 32.1 31.2 30.4 60.8 63.3 52.2 45.7 45.2 46.0 

Suicide 17.6 18.0 20.1 20.2 20.0 19.9 6.4 8.0 10.0 10.8 11.6 10.3 

Homicide 3.6 6.8 9.1 9.2 10.1 10.9 36.7 67.6 69.6 58.7 64.6 66.6 



Female 
Motor vehicle 

accidents 11.2 14.8 11.4 13.1 13.0 12.8 9.7 13.4 9.3 9.7 8.9 8.3 

All other accidents . 20.4 18.3 16.7 15.4 14.6 14.4 29.1 22.5 18.9 17.2 17.0 18.6 

Suicide 5.3 7.1 7.4 6.9 6.6 5.9 1.6 2.6 2.7 2.8 2.8 2.2 

Homicide 1.4 2.1 2.9 2.9 3.0 3.2 10.4 13.3 15.1 13.0 13.8 13.5 



includes persons under 15 years old, not shown separately 
"Figure does not meet standards of reliability or precision. 

Source: U.S. National Center for Health Statistics. Vital Statistics of the United States, 1982-83 annual and unpublished data. Taken 
from U.S. Bureau of the Census, Statistical Abstract of the United States U S Government Printing Office, Washington, DC, 
December 1982. Table 1 18, p. 79. and National Center for Health Statistics: Advance report, final mortality satitsics, 1980. Monthly 
Vital Statistics Report, Vol. 32, No. 4, Supp. DHHS Pub. N o. (PHS) 83-1 120. Public Health Service, Hyattsville, MD, August 1983. 
Table 8, p. 30 



148 



Table 6 

Age-adjusted accident mortality rates, Indians and Alaska Natives in reservation States, United 
States, and, all races United States, other than white, 1955-1979. 

(Single year rates per 100,000 population) 





Indian and Alaska Native 


U.S. 


All R; 




U.S. 


Other Than White 




Calendar 


A II 

All 


Motor 




All 


Motor 




All 


Motor 




Year 


Accidents 


Vehicle 


umer 


Accidents 


Vehicle 


Other 


Accidents 


Vehicle 


Other 


1979 1 


140.7 


79.3 


61.4 


43.7 


23.7 


20.0 


50.5 


21.5 


29.0 


1978 1 


160.8 


91.9 


68.9 


44.3 


23.4 


20.9 


52.6 


22.4 


30.1 


19771 


155.5 


90.2 


65.3 


43.8 


22.4 


21.4 


53.1 


21.9 


31.2 


1976 1 


159.2 


91.2 


68.0 


43.2 


21.5 


21.7 


53.2 


21.9 


31.3 


1975 


170.5 


94.1 


76.4 


44.8 


21.3 


23.5 


56.9 


22.5 


34.4 


1974 


163.2 


86.7 


76.5 


46.0 


21.8 


24.2 


58.5 


23.2 


35.3 


1973 


202.7 


117.1 


85.6 


51.7 


26.4 


25.3 


67.5 


30.0 


37.6 


1972 


185.1 


107.1 


78.0 


52.0 


27.0 


25.0 


68.8 


30.6 


38.1 


1971 


183.0 


96.5 


86.5 


52.0 


26.6 


25.3 


71.6 


31.3 


40.4 


1970 


181.8 


98.5 


83.3 


53.7 


27.4 


26.3 


72.8 


30.9 


41.9 


1969 


194.4 


99.1 


95.3 


55.3 


28.5 


26.8 


75.5 


33.7 


41.8 


1968 


183.0 


94.5 


88.5 


55.1 


28.4 


26.7 


77.0 


33.3 


43.7 


1967 


178.9 


95.5 


83.4 


54.8 


27.8 


27.0 


73.2 


31.1 


42.1 


1966 


185.2 


92.4 


92.8 


55.6 


28.3 


27.3 


75.8 


31.6 


44.1 


1965 


186.7 


91.9 


94.8 


53.4 


26.6 


26.8 


70.8 


29.2 


41.5 


1964 


208.5 


97.3 


111.1 


52.0 


25.7 


26.3 


68.4 


27.5 


40.8 


1963 


172.5 


78.0 


94.5 


50.9 


24.3 


26.6 


68.2 


26.5 


41.7 


1962 


176.2 


87.6 


88.6 


49.7 


23.1 


26.6 


66.5 


25.2 


41.3 


1961 


188.8 


91.5 


97.4 


48.1 


22.1 


26.1 


63.3 


23.9 


39.4 


1960 


186.1 


91.9 


94.6 


49.9 


22.5 


27.4 


67.3 


24.4 


42.9 


1959 


197.4 


98.3 


99.1 


49.9 


22.8 


27.1 


66.1 


25.0 


41.1 


1958 


172.3 


87.4 


84.9 


49.8 


22.5 


27.3 


66.7 


24.7 


42.0 


1957 


185.1 


94.9 


90.9 


53.4 


24.1 


29.3 


71.0 


27.3 


43.7 


1956 


195.5 


106.2 


89.4 


54.4 


25.2 


29.2 


72.0 


29.5 


42.5 


1955 


184.0 


97.6 


90.3 


54.3 


24.6 


29.7 


71.1 


28.1 


43.0 



1 Estimated population methodology revised in 1976. Maine, New York and Pennsylvania included as reservation States 
beginning in 1979, 

Source: Indian and Alaska Native— Indian Health Service. U.S. all Races and U.S. Other than White— National Center for 
Health Statistics, Annual Mortality Publication. Vol. II, Part A (1955-1975) and Annual Advance Mortality Reports (1976-1979) 
Taken from FY 1984 Budget Appropriation Indian Health Service "Chart Series" Tables Vital Events Branch, Office of Pro- 
gram Statistics, Division of Resource Coordination. Indian Health Service, Rockville, MD, April 1983. 



Table 7 

Mortality from fires and flames, United States, 1976-77 









Average Annual Death Rate per 100,000 Population 










Total Persons 






White 






Nonwhite 




Age Group 


i otai 


Male 


Female 


i otai 


Male 


Female 


Total 


Male 


Female 


All anps 


2 9 


3.7 


2.2 


2.5 


3.1 


1 .9 


6.0 


7.8 


4.6 


Under 1 


4.9 


5.0 


4.7 


3.4 


3.7 


3.2 


11.8 


11.5 


12.0 


1-4 


5.3 


5.9 


4.6 


4.0 


4.5 


3.5 


11.2 


12.3 


10.0 


5-9 


2.0 


2.2 


1.9 


1.6 


1.7 


1.5 


4.3 


4.6 


3.9 


10-14 


1.1 


1.1 


1.0 


.9 


1.0 


.9 


2.0 


2.1 


1.9 


15-19 


1.2 


1.4 


.9 


1.1 


1.3 


.9 


1.6 


2.0 


1.2 


20-24 


1.7 


2.3 


1.1 


1.6 


2.1 


1.0 


2.7 


3.4 


2.1 


25-34 


1.7 


2.5 


.9 


1.5 


2.2 


.8 


3.4 


5.2 


1.9 


35-44 


2.0 


2.8 


1.2 


1.7 


2.3 


1.1 


4.2 


6.7 


2.2 


45-54 


2.9 


3.9 


1.9 


2.4 


3.1 


1.6 


6.9 


10.4 


3.9 


55-64 


4.1 


5.8 


2.7 


3.5 


4.8 


2.3 


10.4 


15.3 


6.2 


65-74 


5.8 


8.2 


4.0 


4.7 


6.5 


3.3 


16.5 


23.5 


10.8 


75 and over . . . 


. 11.6 


15.5 


9.3 


9 6 


13.2 


7.6 


32.6 


37.8 


29.1 



Note All deaths resulting from conflagraton and other types of fires, except in transportation, are included regardless of the nature 
of the injury 

Source of basic data: Reports of the Division of Vital Statistics, National Center for Health Statistics Taken from Metropolitan Life 
Insurance Company Statistical Bulletin, October-December 1979. Table 1, p. 5 



Table 8 

Mortality from fires and flames by age, race, and sex. United States, 1968-69 

Average Annual Death Rate per 100,000 
Total Persons White Nonwhite 



Ai ji : Grou| ) 


Total 


Male 


Female 


Total 


Male 


Female 


Total 


Male 


Female 


All ages 


3.6 


4.4 


2.9 


2.9 


3.6 


2.3 


8.5 


10.1 


6.9 


Under 1 


5.4 


5.4 


5.4 


3.2 


3.0 


3.3 


15.6 


16.5 


14.8 


1-4 


5.8 


6.3 


5.4 


3.8 


4.2 


3.4 


15.7 


16.3 


15.1 


5-9 


2.3 


2.3 


2.3 


1.7 


1.7 


1.6 


5.7 


5.5 


5.9 


10-14 


1.0 


1.1 


0.8 


0.8 


0.9 


0.7 


2.0 


2.2 


1.9 


15-19 


0.9 


1.0 


0.7 


0.7 


0.9 


0.6 


1.9 


2.2 


1.6 


20-24 


1.3 


1.9 


0.8 


1.1 


1.6 


0.7 


2.7 


3.9 


1.6 


25-34 


1.8 


2.5 


1.1 


1.5 


2.0 


0.9 


4.2 


6.3 


2.3 


35-44 


2.7 


3.7 


1.8 


2.3 


3.0 


1.5 


6.5 


9.5 


4.0 


45-54 


3.9 


5.2 


2.7 


3.4 


4.4 


2.5 


8.4 


12.5 


4.8 


55-64 


5.8 


7.8 


4.0 


5.0 


6.6 


3.6 


13.5 


19.3 


8.4 


65-74 


8.0 


10.3 


6.1 


6.2 


8.1 


4.7 


29.3 


35.6 


23.9 


75 and over . . 


16.0 


20.6 


13.0 


13.5 


18.0 


10.4 


45.0 


46.8 


43.7 



Note: All deaths resulting from conflagration or ignition burning by fire, except in transportation, are included regardless of the 
nature of the injury. 

Source of basic data: Reports of the Division of Vital Statistics, National Center for Health Statistics Taken from Metropolitan Life 
Insurance Company Statistical Bulletin, December 1973 Table 1, p. 6 



150 



Table 9 

Blood lead levels of persons 6 months-74 years, with mean, standard error of the mean, median, and percent distribution, by race 
and age, United States 1976-80. 



Blood lead level (^g/dl) 



ndUc dllU dyt? 


Estimated 
population 
i n 

thousands 1 


M I i m heir 
IN Ul 1 1 UfcM 

examined 2 


lvlt.dl I 


Standard 

t-1 I Ul Ul 

the mean 


ivicuidl I 


Less 

than 
LI Idl I 

10 


10-19 


20-29 


30-39 


40 4Q 


JU J3 




All races 3 














Percent distribution 


4 






All a n ac 

MM dytJo 








0 94 


I o . u 


99 1 


62.9 


13.0 


1 .6 


0 9 


n 1 


0 0 


6 months-5 years . . 


16,862 


2,372 


16.0 


0.42 


15.0 


12.2 


63.3 


20.5 


3.5 


0.3 


0.1 


0.0 


6-17 years 


44,964 


1,720 


12.5 


0.30 


12.0 


27.6 


64.8 


7.1 


0.5 








18-74 


141,728 


5,841 


14.2 


0.25 


13.0 


21.2 


62.3 


14.3 


1.8 


0.3 


0.1 


0.0 


White 


























r\\\ dytJo 


1 74 


ft ?6Q 


1 ? 7 


n 94 


IO.U 


9^ ft 


62.8 


12.2 


1.5 


n 9 

u . c 


n 1 


0 0 
u . u 


6 months-5 years . . 


13,641 


1,876 


14.9 


0.43 


14.0 


14.5 


67.5 


16.1 


1.8 


0.1 


0 1 


0.0 


6-17 years 


37,530 


1,424 


12.1 


0.30 


11.0 


30.4 


63.4 


5.8 


0.4 








18-74 years 


123,357 


5,069 


14.1 


0.25 


13.0 


21.9 


62.3 


13.7 


1.8 


0.3 


0.1 


0.0 


Black 


























All ages 


23,853 


1,332 


15.7 


0.48 


15.0 


13.3 


63.7 


20.0 


2.3 


0.3 


0.2 


0.1 


6 months-5 years . 


2,584 


419 


20.9 


0.61 


20.0 


2.5 


45.4 


39.9 


10.2 


1.4 


0.5 


0.1 


6-17 years 


6,529 


263 


14.8 


0.53 


14.0 


12.8 


70.9 


15.6 


0.7 








18-74 years 


14,740 


650 


15.5 


0.54 


14.0 


14.7 


6;^ 9 


19.6 


2.0 


0.4 


0.3 


0.2 



'At the midpoint of the survey, March 1, 1978 

2 With lead determinations from blood specimens drawn by venipuncture, 
includes data for races not shown separately. 
4 Numbers may not add to totals due to rounding. 

Source: National Center for Health Statistics: Blood lead levels for persons 6 months-74 years of age: United States 1976-80. Ad- 
vance Data From Vital and Health Statistics, No. 79. DHHS Pub No (PHS) 82-1250. Public Health Service, Hyattsville, MD, 
May 12, 1982. Table 1, p. 6 



151 



Table 10 

Homicide deaths and rates 1 per 100,000 population for Indians and Alaska Natives in reservation States and for United States, all races 
and other than white, 1959-79 

Number Crude Rates Age-Adjusted Rates and Their Ratio 

United States: Ratio of Indians to: 



YG3.r 


InHianc onri 
1 1 itJidi lo di lvJ 

Mldorxd INdllvt/O 


All Roppc 


1 1 ILJIdi lo dl ILJ 
A 1 Q c \< Q M at i woe 


1 1 9 

\J . O . 

All RarpQ 

MM RdL/Go 


1 1 iLJidi lo di ilj 

A 1 3 c Lc q t\l ati \/oc 
rAldorVd INdLIVtzJo 


All 

r\\\ 


Othor than 
\Jv\ lt:l LI id! I 

v V I II It; 


I I 9 All 

LJ.O. nil 
ndUcb 


I I 9 Hthor 

Than \A/hito 
I 1 Idl ) VVI IILtJ 


1979 


209 


22,550 






25.5 


10.4 


36.0 


2.5 


0.7 


1978 


218 


20,432 


22.1 


9.4 


27.8 


9.6 


33.4 


2.9 


0.8 


1977 


197 


19,968 


22.3 


9.2 


26.5 


9.6 


34.5 


2.8 


0.8 


1976 


185 


19,554 


21.8 


9.1 


26.6 


9.5 


36.4 


2.8 


0.7 


1975 


185 


21,310 


23.0 


10.0 


26.5 


10.5 


41.1 


2.5 


0.6 


1974 


203 


21,465 


24.4 


10.2 


30.1 


10.8 


44.5 


2.8 


0.7 


1973 


196 


20,465 


24.2 


9.8 


29.6 


10.5 


44.4 


2.8 


0.7 


1972 


159 


19,638 


22.5 


9.4 


27.6 


10.3 


46.6 


2.7 


0.6 


1971 


149 


18,787 


19.9 


9.1 


26.1 


10.0 


46.8 


2.6 


0.6 


1970 


125 


16,848 


19.3 


8.3 


23.8 


9.1 


41.3 


2.6 


0.6 


1969 


132 


15,477 


18.3 


7.7 


22.5 


8.6 


40.5 


2.6 


0.6 


1968 


116 


14,686 


18.1 


7.3 


22.2 


8.2 


38.8 


2.7 


0.6 


1967 


110 


13,425 


15.9 


6.8 


20.3 


7.7 


36.3 


2.6 


0.6 


1966 


79 


11,606 


15.7 


5.9 


20.3 


6.7 


31.9 


3.0 


0.6 


1965 


102 


10,712 


14.7 


5.5 


19.7 


6.3 


29.8 


3.1 


0.7 


1964 


84 


9,814 


17.1 


5.1 


23.6 


5.8 


27.6 


4.1 


0.9 


1963 


85 


9,225 


16.0 


4.9 


22.3 


5.5 


26.6 


4.1 


0.8 


1962 


80 


9,013 


14.8 


4.8 


21.0 


5.5 


26.3 


3.8 


0.8 


1961 


63 


8,578 


14.7 


4.7 


20.9 


5.3 


24.9 


3.9 


0.8 


1960 


80 


8,464 


13.7 


4.7 


19.5 


5.3 


25.8 


3.7 


0.8 


1959 


62 


8,159 


14.5 


4.6 


20.5 


5.1 


25.8 


4.0 


0.8 



1 lndian and Alaska Native crude rates are 3-year averages centered in the year specified All other rates are based on single-year 
data. Estimated population methodology for the Indian population revised in 1976. Maine, New York and Pennsylvania included 
as reservation States beginning in 1979. The homicide category was revised to include homicide and legal intervention beginning 
in 1979, in accordance with the Ninth Revision to the International Classification of Diseases, Clinical Modification. 
Source: FY 1984 Budget Appropriation Indian Health Service "Chart Series" Tables. Vital Events Branch, Office of Program Statistics, 
Division of Resource Coordination Indian Health Service, Rockville, MD. April 1982 



152 



Table 11 

Number and percent distribution of office visits of black patients and percent distribution of office visits of all patients, by major 
diagnostic groups and inclusive ICDA codes: United States, 1975-76. 





Number of 






visits of 


Visits by- 


Major diagnostic groups and inclusive ICDA codes 1 


black 






patients in 


Black All 




thousands 


patients patients 2 



All visits 90,484 

Infective and parasitic diseases 000-136 4,410 

Neoplasms 1 40-239 1 ,468 

Endocrine, nutritional, and metabolic diseases 240-279 4,270 

Mental disorders 290-315 3,068 

Diseases of nervous system and sense organs 320-389 4,998 

Diseases of circulatory system 390-458 9,366 

Diseases of respiratory system 460-519 14,704 

Diseases of digestive system 520-577 2,999 

Diseases of genitourinary system 580-629 6,822 

Diseases of skin and subcutaneous tissue 680-709 4,445 

Diseases of musculoskeletal system 710-738 5,271 

Symptoms and ill-defined conditions 780-796 4,063 

Accidents, poisonings, and violence 800-999 8,140 

Special conditions and examinations without sickness Y00-Y13 14,295 

Other diagnoses 3 1 ,365 

Diagnosis "none" or "unknown" 788 

'Based on Eighth Revision International Classification of Diseases, Adapted for Use in the United States, ICDA. 
2 Based on 1,155,900,228 office visits by patients of all races over the 2-year span 1975-76. 

3 Diseases of blood and blood-forming organs; complications of pregnancy, childbirth and the puerperium; congenital anomalies; 
and certain causes of prenatal morbidity and mortality- 
Source: National Center for Health Statistics: Office Visits by Black Patients, National Ambulatory Medical Care Survey: United States, 
1975-76. Advance Data from Vital and Health Statistics. No 50. DHEW Pub. No. (PHS) 79-1250. Public Health Service, Hyattsville, 
MD, July 23, 1979. 



Percent distribution 
100.0 100.0 



4.9 
1.6 
4.7 
3.4 
5.5 
10.4 
16.3 
3.3 
7.5 
4.9 
5.8 
4.5 
9.0 
15.8 
1.5 
0.9 



4.2 
2.2 
4.2 
4.2 
8.2 
9.6 

14.1 
3.3 
6.2 
5.3 
5.7 
4.7 
7.3 

18.1 
1.4 
1.3 



Table 12 

Number of discharges for patients discharged from short-stay hospitals, by selected diagnoses (in- 
cluding ICD codes) and race: United States, 1971 and 1980. 

1980' 1971* 

Total White All Other Total White All Other 

All Conditions 37,832 28,484 4,879 25,789 22,451 3,338 

Injury and violence, Poisonings 3,593 2,658 473 2,664 2,315 349 

800-999 

Fractures, All Sites 1,163 882 118 772 693 79 

800-829 

Sprains and Strains of back 312 223 48 222 202 20 

(including neck) 
846-847 

Intracranial Injuries (excluding those with 295 215 43 229 197 32 

skull fracture) 
850-854 

Lacerations and open wounds 334 227 70 327 258 69 

870-907 (1971) 

870-904 (1980) 

"Includes inpatients for when sex and color were not stated. 

Source: Abstracted and Compiled by CHESS from 1) National Center for Health Statistics: A.L Ranofsky: Inpatient utilization of 
short-stay hospitals by diagnosis. Vital and Health Statistics Series 13, No. 16 DHEW Pub. No. (HRA) 75-1767 Public Health Serv- 
ice, Rockville, MD. Government Printing Office, July 1974, Table 2, pp. 30-35. 2) National Center for Health Statistics: B.J. Haupt: 
Utilization of short-stay hospitals: Annual Summary. Vital and Health Statistics, Series 13, No. 64. DHHS Pub. No. (PHS) 82-1725. 
Public Health Service. Washington, DC Government Printing Office, March, 1982. Table 14. p. 35. 



153 



References 

1 . Public Health Service: Pro- 
moting Health/Preventing 
Disease: Public Health Serv- 
ice Implementation Plans for 
Attaining the Objectives of 
the Nation, PHS 83-501 93A 
(USPS324-990), Public Health 
Reports, Supplement to the 
September-October 1983 
Issue. 

2. National Safety Council: 
Accident Facts 1979 Edition, 
Chicago, IL, 1979. 

3. Hanlon, John J., and 
Pickett, George E.: Public 
Health: Administration and 
Practice, C.V. Mosby Com- 
pany. St. Louis, Toronto, Lon- 
don, 1979. 

4. Burton, Lloyd Edward, 
Smith, Hugh Hollingsworth, 
and Nichols, Andrew. 
Wilkinson: Public Health and 
Community Medicine, Third 
Edition. Williams and Wilkins, 
Baltimore/London, 1980. 

5. Metropolitan Life In- 
surance Company: Statistical 
Bulletin, Vol. 60, No. 2, April- 
June 1979. 

6. Public Health Service: Pro- 
moting Health/Preventing 
Disease: Objectives for the 
Nation, Office of the Assistant 
Secretary for Health, U.S. 
Department of Health and 
Human Services, Fall 1980. 

7. "The Epidemiology of 
Road Traffic Accidents." 
Report on a Conference. 
Vienna, November 4-7, 1975. 
World Health Organization, 
Copenhagen, 1976. 

8. "Alcoholism a High Priority 
Health Problem," a report of 
the Indian Health Service 
Task Force on Alcoholism. 
U.S. Department of Health, 
Education, and Welfare. 
Public Health Service. Indian 
Health Service. Pub. No. 
(HSA) 77-1001. DHEW 
Rockville, MD, 1977. 

9. The Nation's Health. 
"DOT: Traffic Deaths Drop- 
ped to 20-year Low: 43,028." 
March, 1984. 



10. The Nation's Health. May 
1983. 

1 1 . National Center for 
Health Statistics: Advance 
report, final mortality 
statistics, 1980. Monthly Vital 
Statistics Report, Vol. 32, No. 
4 Supp. DHHS Pub. No. 
(PHS) 83-1120. Public Health 
Service, Hyattsville, MD, 
August 1983. 

12. Vital Statistics of the 
United States 1978, Vol. II, 
Mortality, Part A, U.S. Depart- 
ment of Health and Human 
Services. U.S. Government 
Printing Office, Hyattsville, 
MD, 1982. 

13. Metropolitan Life In- 
surance Company: Statistical 
Bulletin, October-December 
1979. 

14. Metropolitan Life In- 
surance Company: Statistical 
Bulletin, December 1973. 

1 5. International Classifica- 
tion of Diseases, 9th Revi- 
sion, World Health Organiza- 
tion, Edwards Brothers, Inc., 
Ann Arbor, Ml, 1978. 

16. National Center for 
Health Statistics: Annest, J.L., 
Mahaffey, K.L., Cox, D.H., 
and Roberts, J.: Blood lead 
levels for persons 6 
months-74 years of age: 
United States, 1976-80. Ad- 
vance Data From Vital and 
Health Statistics, No. 79. 
DHHS Pub. No. (PHS) 
82-1250. Public Health Serv- 
ice. Hyattsville, MD, May 
1982. 

17. Center for Disease Con- 
trol: "Blood-Lead Levels in 
U.S. Population." Morbidity 
and Mortality Weekly Report. 
Vol. 31, No. 10. Atlanta, GA, 
March 1982. 

18. Center for Disease Con- 
trol: "Surveillance of 
Childhood Lead Poisoning- 
United States." Morbidity and 
Mortality Weekly Report Vol. 
30, No. 34. Atlanta, GA, 
September 1981. 

19. National Center for 
Health Statistics: Health 
United States, 1982, DHHS 



Pub. No. (PHS) 83-1232. 
Public Health Service. 
Washington, DC. U.S. 
Government Printing Office, 
December 1982. 
20. U.S. Bureau of the Cen- 
sus: Statistical Abstract of the 
United States: 1982-83 U.S. 
Government Printing Office, 
Washington, DC, December 
1982. 

List of Tables 

1 . Age-adjusted death rates 
for accidents, by color and 
sex: United States, selected 
years from 1950 to 1980. 

2. Age-specific accident 
death rates. 

3. Mortality from motor vehi- 
cle accidents, selected coun- 
tries, 1965-66 and 1975-76. 

4. Age-adjusted death rates 
for motor vehicle accidents, 
by color and sex: United 
States, selected years from 
1950 to 1980. 

5. Death rates from ac- 
cidents and violence: 1960 to 
1980. 

6. Age-adjusted accident 
mortality rates, Indians and 
Alaska Natives in reservation 
States, United States, all 
races, and United States, 
other than white, 1955-1979. 

7. Mortality from fires and 
flames, United States, 
1976-77. 

8. Mortality from fires and 
flames by age, race, and 
sex, United States, 1968-69. 

9. Blood lead levels of per- 
sons 6 months to 74 years 
with mean, standard error of 
the mean, median, and per- 
cent distribution by race and 
age, United States, 1976-80. 

10. Homicide deaths and 
rates per 100,000 population 
for Indians and Alaska 
Natives in reservation States 
and for U.S., all races and 
other than white, 1959-1979. 



11. Number and percent 
distribution of office visits of 
black patients and percent 
distribution of office visits of 
all patients, by major 
diagnostic groups and in- 
clusive ICDA codes: United 
States, 1975-76. 

12. Number of discharges 
for patients discharged from 
short-stay hospitals, by 
selected diagnoses (including 
ICD codes) and race: United 
States, 1971 and 1980. 

List of Figures 

1. Accidental deaths and in- 
juries in 1978. 

2. Age-adjusted accident 
death rates. 

3. Mean blood lead levels 
(PbB) of children ages 6 
months to 5 years in large ur- 
ban areas: United States, 
1976-80. 

4. High blood lead levels in 
children 6 months-5 years of 
age, according to family in- 
come and race: United 
States, annual average, 
1976-80. 



154 



Chapter VII 



Mental Health 



Table of Contents 

Overview 157 

A. Introduction 158 

B. Some Limitations in Making 
Cross-Group Comparisons 159 

C. Utilization of Psychiatric Facilities 159 

D. Diagnostic Categorization 161 

E. Mental Disorders among Native Americans 164 

F. Drug Abuse 165 
Tables 167 
References 181 
List of Tables 181 
List of Figures 181 



155 



156 

■ 



Chapter VII 



Mental Health 



Overview 

There are two major models 
for conceptualizing mental 
health problems: a medical 
model and a social model. 
The social model would dic- 
tate the analysis of data con- 
cerning the utilization of 
nonmedical practitioner and 
nonmedical institutional data 
that are not generally 
available. One such set of 
data that are available are 
presented. These data con- 
cern inmates in penal institu- 
tions and show that blacks, 
Hispanics, and Native 
Americans are incarcerated 
in Federal prisons at rates 
three times their proportion of 
the U.S. population, and that 
blacks are incarcerated in 
State prisons at rates four 
times their proportion in the 
U.S. population. 

Because of the paucity of 
data based on the social 
model, only data based on 
the medical model are 
analyzed in this chapter. 
Essentially, these data consist 
of utilization data and data 
based on diagnostic 
categories disaggregated by 
racial/ethnic characteristics. 

Patient care episodes for 
both inpatient and outpatient 
care increased almost four- 
fold during the 24-year 
period from 1955 to 1979. 
Episodes per 100,000 
population increased almost 
threefold during that period. 
At the beginning of the 
period, outpatient visits ac- 
counted for only 23 percent 
of all psychiatric episodes, 
but by the end of the period, 
72 percent of all episodes 
were handled in an outpa- 
tient setting. 

In the decade 1970-1980, 
there was a 24 percent in- 
crease in the number of 



facilities providing mental 
health care, even though 
there was a decline in the 
number of State and county 
mental hospitals. The biggest 
increase was among federally 
funded community mental 
health centers. Inpatient beds 
decreased by 47.7 percent in 
1970-1980, again underscor- 
ing the trend away from the 
inpatient treatment setting. 

In 1970-1980, there was 
only a 20.2 percent increase 
in inpatient additions, while 
outpatient additions increased 
by almost 130 percent and 
day treatment additions in- 
creased by almost 21 1 
percent. 

There are some strong in- 
terrelationships between sex, 
race, and the type of facility 
utilized. Males utilized State 
and county mental hospitals 
by a factor of almost 2 to 1 
over women among both 
whites and nonwhites, while 
nonwhites utilized that facility 
type by almost the same 2 to 
1 ratio. Private mental 
hospitals showed a reversal 
of this pattern. They were 
used by whites 71 percent 
more than nonwhites, and by 
females 27 percent more 
than males. Outpatient 
psychiatric services are used 
more heavily by nonwhites 
(by about 30 percent) and by 
females (14 percent by 
whites, 10 percent for 
nonwhites). 

While male use of non- 
Federal general hospital 
psychiatric units was about 
equal between the two racial 
groups, nonwhite females us- 
ed them more (22 percent) 
than their male counterparts, 
and white females used them 
disproportionately even more 
(36 percent). 

Hispanics used all facility 
types less than would have 



been expected from their 
proportion of the population, 
with the exception of their in- 
patient use of public general 
hospitals. The use of outpa- 
tient psychiatric services by 
Hispanics appears to have 
been on the increase. 

Generally, whites were ad- 
mitted to facilities (both inpa- 
tient and outpatient) at later 
ages than blacks or 
Hispanics, and females were 
admitted at later ages than 
males. 

Those using mental health 
care facilities had an equal or 
higher educational level than 
did their racial/ethnic group 
in general. 

The types of disease 
categories ascribed to pa- 
tients varied by sex, race, 
and facility type. Community 
mental health centers had a 
higher caseload of alcoholism 
and childhood disorders, 
general hospitals had a 
higher depression caseload, 
and outpatient psychiatric 
services had a higher 
caseload of transient 
disorders and social 
maladjustment. 

Ten disease categories 
were analyzed. Using facility 
utilization as a criterion, 
alcoholism and drug 
disorders are predominantly 
male and nonwhite problems. 
Depressive disorders are 
predominantly female and 
nonwhite. Schizophrenia is 
predominantly nonwhite; 
neuroses are predominantly 
female and white. Personality 
disorders are predominantly 
white and slightly male. 
Childhood disorders are non- 
white and male; and social 
maladjustment is 
predominantly nonwhite and 
female. The other categories 
did not have as dramatic 
dominance patterns as those 



listed above. We discuss 
nonwhite dominance of 
schizophrenia, and present 
justification for viewing disad- 
vantagedness as one factor 
in the predominance. 

American Indian and 
Native Alaska mental health 
problems have been severe 
in a few diagnostic 
categories. One of these is 
alcoholism, for which the 
death rate has been 
disproportionately high com- 
pared with the overall 
population. This group 
showed a tremendous 
decrease in hospital 
discharge rates for 
alcoholism in the 11 -year 
period ending in 1982, dur- 
ing which the ratio with the 
overall U.S. population 
decreased from 7.08 to 1.67. 
Suicide rates had undergone 
some decreases almost to 
parity by 1965, then 
increased to over twice the 
Non-Indian rate in the next 
10 years. Homicide rates 
have remained high. 

Blacks, Puerto Ricans, 
and Mexican-Americans have 
been over-represented in 
drug abuse clinic utilization, 
American Indians and 
Cubans have been propor- 
tionately represented, and 
whites and Asians have been 
under-represented. Recent 
surveys by the Institute for 
Social Research, University of 
Michigan, have shown a con- 
stant downward trend in drug 
use among American youths. 
Marijuana use dropped 10 
percent from 1979 to 1983, 
and from 1982 to 1983 there 
was a 1 percent drop in LSD 
and cocaine use, a 14 per- 
cent drop in stimulant use, a 
2 percent drop in sedative 
use, and a 2 percent drop in 
alcohol use. 



157 



A. Introduction 

When discussing most health 
problems in this book, we 
have been able to define 
health as the absence of 
disease. It may not seem 
profound to state that a per- 
son is oncologically healthy if 
he or she does not have 
cancer. We can accept such 
a statement because we 
generally share an under- 
standing of what cancer is, 
and we generally can detect 
when a person is in a 
cancerous state. We could 
also accept the statement 
that a person is mentally 
healthy if he or she lacks 
psychopathology, but here 
we run into a problem with 
both definition and 
conceptualization. 

Neurology is a field of 
medicine that has witnessed 
many advances in the 20th 
century. It has been able to 
delineate an area of disease 
and dysfunction of the ner- 
vous system that is 
organically based. What re- 
mains is a group of other 
disorders affecting mental 
functioning that are believed 
to be organic (i.e., 
physiologically based), and 
another group that at least 
some theorists and practi- 
tioners of psychotherapy 
have come to believe is func- 
tional (i.e., disorders that 
result from stress or exposure 
to the vicissitudes of life). 

The organic mental 
diseases are usually believed 
to be such either because 
(a) those who have that 
specific disease also have 
some physiological 
characteristics not found in 
the rest of the population, or 
not found to the same 
degree in the rest of the 
population, or because (b) 
physical treatments (e.g., 
electro-shock therapy) and/or 
pharmaceutical treatments 
seem to ameliorate the symp- 
toms. The functional 



disorders are believed to be 
such because (a) they are 
not sufficiently ameliorated by 
physical or pharmaceutical 
treatments, (b) they respond, 
at least at times, to 
psychotherapy or talking 
treatments, and/or (c) certain 
stress-producing situations, 
both in the laboratory and in 
real-life situations, have 
resulted in what appear to be 
similar conditions. 

There is not always agree- 
ment among theorists and 
practitioners about the 
dividing line between organic 
and functional categories. If 
the above discussion is not 
confusing enough, it at least 
deals with chronic types of 
disorders, or episodes that 
last over a period of days. 
Add to the problem the 
categories of transient mental 
conditions (e.g., people with 
mood swings, people about 
whom it is said "he's having 
a bad day," or transient 
sociopathic [felonious] 
behavior that sometimes lasts 
less than an hour in a person 
who is otherwise relatively 
mentally healthy) and there 
are indeed problems in 
nosology and analysis. These 
problems are of particular in- 
terest in a chapter dealing 
with the comparative mental 
health of the disadvantaged, 
because it is commonly 
believed that persons within 
those racial, ethnic, educa- 
tional, and/or income groups 
are greatly exposed to the 
precursor causes of func- 
tional mental disorders. 

What then is an index of 
mental health status? If we in- 
voke the medical model, we 
consider that mental prob- 
lems are "diseases" or 
"disorders" that are 
"treated" or "cured" by doc- 
tors in hospitals and clinics. 
On that model, health status 
indicators used for other 
health problems could be 
useful here, too. That is, we 



use health care services 
utilization data and distribu- 
tions of demographic 
characteristics by diagnostic 
categories. If we invoke the 
social model, then we use 
tabulations of inmates in 
mental institutions; we employ 
the utilization of services of 
social welfare agencies, crisis 
centers, and counselling 
centers; we invoke unemploy- 
ment rates; we tabulate 
police interventions in family 
and public disputes, etc. 

The point can best be 
understood with an example. 
The table below contains a 
distribution of Federal and 
State prison inmates by 
race/ethnicity. Note that 
blacks populate Federal 
prisons approximately three 
times their proportion in the 
population; they populate 
State penal institutions about 
four times their proportion in 
the population. Hispanics and 
Native Americans also 
populate Federal prisons ap- 
proximately three times their 
proportions in the population, 
but are incarcerated in State 
institutions by factors about 
1.09 and 1.5 their proportion 
of the population. If mental 
health diagnostic manuals 
contain diagnostic categories 
for various types of behaviors 
that result in incarceration, 
then is it not true that these 
figures on incarceration 
reflect mental health 
problems? 



We do not try to resolve 
these issues in this chapter. 
Note that, except for the 
prison data referenced 
above, cited data are related 
to the medical model, 
because these data are 
available, and they are com- 
monly used for such 
purposes. 

The bulk of the data 
available to use for mental 
health status indexes are 
mental health facility utiliza- 
tion data. These data are 
associated with both am- 
bulatory and resident care. 
They exclude data concern- 
ing those who do not seek 
care— and there is no reason 
to believe that persons from 
racial/ethnic minorities and 
low income groups are in 
that category in dispropor- 
tionate numbers. They also 
exclude persons receiving 
care from private practitioners 
(e.g., psychiatric social 
workers, psychiatric nurses, 
and ministers), and those 
receiving attention in 
nonreporting institutions, such 
as schools, churches, social 
welfare agencies, free clinics, 
and crisis counselling 
centers. The groups of con- 
cern in our analysis may be 
disproportionately low among 
those receiving attention by 
private practitioners, and 
disproportionately high 
among those obtaining serv- 
ices from social welfare 
agencies. 



Distribution of Federal and State prison inmates by race/ethnicity' 



Total 

Type of Inmate 
Penal Popu- 

Inst. lation White Black 

Federal 21,858 13,370 7,981 
State 282,398 119,173 126,173 



Native 

Hispanic American Other 

3.715 384 100 

18,928 2,322 1147 



Federal 
State 



Percent 
Black 

36.5 
47.2 



Percent 
Hispanic 

17.0 
7.2 



Percent 
Native 
American 

1.76 
0.9 



'Data provided in correspondence from the American Correctional Association. 



158 



The available data sources 
place a limit on our 
understanding of the degree 
to which the mental health 
problems of minorities and 
low income groups differ 
from those of the total 
population. That limitation is 
due to the lack of incidence 
and prevalence data. 

One final set of nuances 
in mental health service 
utilization must be 
understood in order to inter- 
pret the data presented here. 
Some diagnostic categories 
involve periods of remissions 
or recurrences of acute 
phases of the morbid condi- 
tions. These characteristics 
require that the onset and 
termination of each phase be 
analyzed. Institutional data of 
phase onset and termination 
may be affected by factors 
that are not related to the 
morbidity itself. With inpatient 
utilization, for example, 
prevalence is affected by 

(a) the number of admissions, 

(b) lengths of stay, (c) read- 
missions, (d) releases, and 
(e) deaths. These factors in 
turn may be affected by 

(a) availability of nonresiden- 
tial facilities in the area, 

(b) admission and discharge 
policies of the institution, 

(c) staffing patterns, (d) delay 
in assignment to treatment 
programs, (e) availability of 
an appropriate setting for the 
patients released, and (f) the 
criteria employed for deter- 
mining recovery. Thus the 
measures employed for 
describing health status also 
can reflect administrative and 
medical management styles 
of the facilities. 

Determining prevalence of 
a mental disease is no more 
problematic than determining 
the incidence of the disease. 
Incidence rates require 
establishing when the mental 
health problem began. Thus 
they rely on data from the 



patient, members of the fami- 
ly, or another person's 
knowledge of the patient's 
life. One of the common 
methods uses the first admis- 
sion to a psychiatric facility 
as the date of onset of the 
mental health problem. Using 
the first admission is general- 
ly now recognized as a very 
weak measure of incidence. 
Rates of admission will vary 
from time to time and from 
place to place, as a function 
of the institution, as a func- 
tion of help-seeking 
behaviors, and of the many 
types and changes in the 
care and treatment of the 
mentally ill. For example, at 
one time, those seeking 
psychiatric treatment con- 
sisted mostly of the in- 
capacitated. Now psychiatric 
help is sought for many 
lesser mental health prob- 
lems. Also, most psychiatric 
care was previously rendered 
in inpatient settings in public 
institutions. Now a much 
larger amount of mental 
health care is rendered in 
outpatient settings and in 
noninstitutional settings. 

There have been recent 
attempts to use an 
epidemiological approach for 
gathering mental health in- 
cidence and prevalence data 
searching etiological cor- 
relates. There are no 
published tools as yet, but 
the approach promises to 
mitigate some of the limita- 
tions in the types of mental 
health data discussed above 
(1, p. 319; 2, p. 381). 

Additional caveats on the 
interpretation of the data 
presented are contained in 
Chapter I of this book. 

B. Some Limitations in 
Making Cross-Group 
Comparisons 

Before comparing the ac- 
cessibility and utilization of 
mental health services be- 
tween the poor and nonpoor 
and the white and nonwhite 



populations, some 
sociodemographic factors 
must be taken into considera- 
tion; for example, the pattern 
of institutionalization by dif- 
ferent social classes. Types 
of behavior that are con- 
sidered to be psychiatrically 
abnormal by one 
socioeconomic or ethnic 
group are not always con- 
sidered abnormal by 
members of another. 
Additionally, there seems to 
be some evidence that 
blacks and whites are dif- 
ferentially diagnosed for 
similar behavioral problems. 
For example, Cannon and 
Locke report studies that 
show whites are more likely 
to be diagnosed with 
depressive disorders, while 
blacks and other nonwhites 
are more likely to be 
diagnosed as schizophrenic. 
They hypothesize that this 
tendency to diagnose blacks 
as schizophrenic more fre- 
quently than whites may be 
due to differences in the 
quality of communication be- 
tween black patients and 
their white psychiatrists, in 
comparison to the com- 
munications of white patients 
with white psychiatrists. This 
tendency could also be a 
reflection of the diagnostic 
habits of psychiatrists. Can- 
non and Locke go on to 
report a study by Raskin 
which observed that, when 
age and social class were 
controlled, blacks had a 
more rapid onset of symp- 
toms, received less 
psychoactive medication, and 
probably received less 
psychiatric treatment prior to 
hospitalization than did their 
white counterparts. 

Cannon and Locke also 
report the findings of Simon's 
study, conducted in nine 
State psychiatric hospitals 
serving New York City and 
surrounding areas. The basic 
outcome of the study was 
that a diagnosis of 



schizophrenia, rather than 
depression, was given more 
frequently to blacks than 
whites by hospital personnel. 
Simon states that black 
behavior patterns baffle most 
middle-class-oriented mental 
health professionals, and will 
continue to do so until blacks 
are viewed as a culturally 
distinct group, with unique 
values and coping 
mechanisms. Black 
depressives have a different 
quality of mental disturbance 
than do white depressives. 

According to Cannon and 
Locke's investigations: 
Those patients who are 
classified as clinic or 
facilities, are generally 
felt to receive treatment 
inferior to that received 
by patients who are 
more affluent and 
receive treatment in 
private facilities. The 
poor and disadvantaged, 
usually Black, are more 
likely to be assigned to 
1 5 minute clinics as op- 
posed to longer term 
therapy. They are also 
more likely to be seen 
by inexperienced 
therapists, and given 
drug therapy with 
minimal psychiatric sup- 
port treatment (3). 
Rosen touches only briefly 
on differential diagnostic pat- 
terns, but notes that the 
available data have 
documented the findings of 
many community studies 
showing that the lower 
socioeconomic classes tend 
to receive diagnoses of more 
serious disorders (4). 

C. Utilization of 

Psychiatric Facilities 

Patient care episodes are 
defined as the number of pa- 
tients on the roll of a facility 
at the beginning of the year, 
plus the total additions to the 
facility during the year. Total 



159 



additions during the year in- 
clude new admissions, read- 
missions, and returns from 
long-term leave. There are, 
therefore, duplicated counts 
of individual patients. 

Total patient care 
episodes, which include both 
hospitalized mental patients 
and ambulatory mental pa- 
tients, increased almost four- 
fold from 1955 to 1979, while 
episodes per 100,000 
population increased almost 
threefold. The bulk of the in- 
crease was in outpatient 
facility settings. In 1955, out- 
patient visits accounted for 
only 23 percent of all 
psychiatric episodes; by 
1979, the figure was 72 
percent. 

In the decade 1970-1980, 
there was a 24.0 percent in- 
crease in the number of 
facilities providing mental 
health care. State and county 
mental hospitals and free- 
standing psychiatric outpa- 
tient clinics were the only 
types of facilities posting 
declines (9.7 and 5.0 percent 
fewer, respectively). The re- 
maining facility types all 
posted increases in the 
number of facilities: private 
psychiatric hospitals (22.7 
percent), non-Federal general 
hospitals with psychiatric 
services (15.8 percent), 
Veteran's Administration (VA) 
psychiatric services (18.3 per- 
cent), federally funded com- 
munity mental health centers 
(252.6 percent), residential 
treatment centers for emo- 
tionally disturbed children 
(41.0 percent), and all other 
facilities (37.3 percent). 

There are three modes of 
service with respect to 
residence: inpatient services, 
under which the patient 
resides within the facility: out- 
patient services, under which 
the patient visits the facility 
only for purposes of 
diagnosis and/or treatment; 
and day treatment, under 



which the patient spends 
almost all days at the facility 
but leaves to spend the night 
elsewhere. The numbers of 
facilities offering each of 
these service modes, and the 
changes in those numbers in 
1970-1980, can be found in 
Table 1 . 

In 1970-1980, the number 
of inpatient beds decreased 
by 47.7 percent, with 62.6 
percent of the decrease oc- 
curring within State and 
county mental hospitals. 
These statistics reflect both 
the trend of decreased use of 
State and county mental 
hospitals and the trend away 
from inpatient services. 

The trend away from State 
and county mental hospitals 
invites further inspection, 
since they are facilities that 
treat a disproportionately 
large number of minority and 
low income patients. 

During 1969-1979, there 
was a 20.2 percent increase 
in inpatient additions, a 129.8 
percent increase in outpatient 
additions, and a 210.6 per- 
cent increase in day treat- 
ment additions in all reporting 
institutions. As can be seen 
in Table 2, the largest con- 
tribution to inpatient additions 
came from federally funded 
community mental health 
centers, although substantial 
contributions came from non- 
Federal general hospital 
psychiatric services, 
Veteran's Administration 
psychiatric services, and 
private psychiatric hospitals. 
State and county mental 
hospitals posted a 21.2 per- 
cent drop in inpatient addi- 
tions during this time. Most of 
the outpatient additions came 
from federally funded com- 
munity mental health centers, 
although free-standing 
psychiatric outpatient clinics 
also made a substantial con- 
tribution to this sharp rise. 
Most of the day treatment ad- 
ditions were due to increased 
utilization of federally funded 



community mental health 
centers. 

The changes noted above 
are of interest in a com- 
parative analysis of minorities 
and low income groups 
because of the way these 
groups use these facilities 
relative to the rest of the 
population. 

Since 1955, there has 
been an uninterrupted 
decrease in the number of 
resident patients in State and 
county mental hospitals. By 
1980, the 25-year decline 
resulted in a 75 percent 
reduction of resident State 
and county mental hospital 
patients, even though admis- 
sions to such facilities con- 
tinued to grow by a factor of 
2.26 from 1955 to 1971. 
Starting in 1972, there was a 
decline of 6.5 percent over 
the next 4 years. The 30-year 
history can be found in 
Table 3. 

The first year of the 
decline of resident State and 
county mental hospital pa- 
tients, 1956, coincided with 
the large-scale introduction of 
psychotropic drugs. In the 
early 1960's, other factors 
were significant in reducing 
the resident populations. 
These factors included more 
efficient admission and 
discharge procedures, more 
effective utilization review pro- 
cedures, increases in the 
availability and use of alter- 
native resources in the com- 
munity, a gradual reduction 
in the residential average 
length of stay, and the 
general adoption of a 
deinstitutionalization 
philosophy. The community 
mental health center became 
an increasingly significant 
resource, both in the number 
of patients it served and in 
the number of facilities in 
existence. 

Table 4 lists a breakdown 
of the 1,180,000 additions to 
federally funded community 
mental health centers in 



1978. From the listing in this 
table it can be seen that 
(a) nonwhites used such 
facilities almost proportionally 
to their numbers in the 
general population, (b) males 
and females used these 
facilities almost equally, (c) 
the age distribution of the pa- 
tients of these facilities were 
quite parallel between the 
racial groups and within each 
sex group, and (d) males 
tended to use these facilities 
at earlier ages than did 
females (which was also true 
of utilization patterns of other 
types of psychiatric facilities). 

Additional facility utilization 
characteristics can be seen in 
Table 5. It is difficult to 
analyze all facilities by a 
single measure, since they 
tend to report differently. 
State and county mental 
hospitals, private mental 
hospitals, and outpatient 
psychiatric services reported 
admissions to their facilities; 
Veteran's Administration 
hospital psychiatric inpatient 
units and non-Federal 
general hospital psychiatric 
inpatient units reported 
discharges; community men- 
tal health centers reported 
additions. 

Table 5 reports the most 
recent published data that in- 
clude racial breakdowns by 
facility type. Some of the 
race/sex utilization trends 
discernible from Table 5 are: 

a) In State and county 
hospitals, male utilization out- 
numbered female utilization 
1.95 to 1. This was true in 
both racial groups. The male- 
to-female utilization ratio for 
whites was 1 .93, and the 
male-to-female ratio for non- 
whites was 2.1 0. 

b) Racially, nonwhites used 
such facilities almost exactly 
twice as much as did whites. 
The reverse was true of 
private mental hospitals, 
where the ratio of white-to- 
nonwhite utilization was 1.71. 
Among whites, females uti- 



160 



lized such facilities 27 per- 
cent more than males did, 
but there was no similar sex- 
ual disparity among 
nonwhites. 

Outpatient psychiatric 
services were used by non- 
whites 1 1 /3 times the rate 
used by whites. There was a 
slightly heavier usage of 
these facilities by females, 
about 14 percent greater 
female usage than male 
usage among whites, a 10 
percent greater usage by 
females than males among 
nonwhites. 

It is very difficult to make 
any meaningful comparisons 
of VA hospital usage among 
the various racial and sexual 
subgroups because of the 
nature of the population eligi- 
ble to receive treatment in 
such facilities. Such facilities 
get minimal usage by 
females, but exposure risk 
rates for females in this sub- 
population may also be 
minimal. These risk rates 
have not been reported in 
the literature. Also, because 
such institutions can have pa- 
tients with short to fairly pro- 
longed times from military 
discharge until entry, it is dif- 
ficult to describe the popula- 
tion at risk. 

The non-Federal general 
hospitals that have 
psychiatric inpatient units 
showed a use by females 36 
percent greater than by 
males among whites, and 22 
percent greater among non- 
whites. The male utilization 
rates were approximately 
equal between the two race 
groups. White females 
showed an 1 1 percent 
greater use than did non- 
white females. 

Table 4 contains a 
distribution of the additions to 
federally funded community 
mental health centers 
(CMHC) in 1978. Approx- 
imately 20 percent of CMHC 
use was by nonwhites. There 
was a slight difference in sex- 



ual usage within races. Non- 
white females had a 5 per- 
cent lower usage rate than 
nonwhite males, whereas 
white females had a 5 per- 
cent higher usage rate than 
white males. 

Table 6 contains a com- 
parison between Hispanics 
and the total population with 
regard to mental health facil- 
ity use. From these data, it is 
obvious that Hispanics use 
mental health facilities at 
rates lower than their propor- 
tion of the population, with 
the exception of their inpa- 
tient use of public general 
hospitals; the usage rate of 
this type of facility was quite 
high. Both State and county 
mental hospitals and non- 
public, non-Federal general 
hospitals actually had more 
admissions from this popula- 
tion subgroup, but the rate in 
comparison to non-Hispanic 
use was lower. 

Also observable in Table 6 
is the increased use of outpa- 
tient psychiatric services by 
Hispanics. This usage rate 
represents only about two- 
thirds of what would be ex- 
pected proportionally; 
however, it appears that this 
form of care has received 
some acceptance from 
Hispanics. Its acceptance will 
probably increase in coming 
years, if the stigma of institu- 
tionalization was the cause of 
the lower usage rates. 

Table 7 presents admis- 
sion rates related to a 
population base and then 
age adjusted. Comparisons 
among the three groups 
(white, black, and Hispanic) 
indicate that blacks have an 
extremely high usage rate of 
State and county mental 
hospitals and that blacks, as 
well as Hispanics, have a 
very high usage rate of 
public non-Federal general 
hospitals. This is the only 
facility usage rate higher for 
Hispanics than for whites. 
Also note that blacks have a 



higher utilization rate of out- 
patient psychiatric services 
than do whites or Hispanics. 

The breakdown in Table 7 
by sexual subgroups shows 
heavy use of outpatient 
psychiatric services for both 
sexes among blacks. Black 
males, however, use private 
mental hospitals more than 
do black females, even 
though both sexes use this 
facility proportionately less 
than whites. Utilization of 
public non-Federal hospitals 
is higher for both sexes 
among blacks than it is for 
whites, although the use is 
heavier for black males than 
black females. Finally, 
although nonpublic Federal 
general hospitals are used at 
a higher rate by black males 
than by white males, they are 
used less frequently by black 
females than white females. 

Again, the only heavy use 
of a facility noted for 
Hispanics was the public 
Federal general hospitals. 
Such usage rates are higher 
for male Hispanics than they 
are for females. Hispanic 
males utilize State and county 
mental hospitals 
proportionally about the same 
as whites, but Hispanic 
females use these facilities 
about half as much as white 
females do. 

In Table 8, age distribu- 
tions indicate differences be- 
tween the various ethnic 
groups in their facility utiliza- 
tion. Although females across 
the three ethnic groups are 
admitted to outpatient 
psychiatric facilities at roughly 
the same median age, males 
are admitted approximately 6 
years earlier than females in 
both the white and Hispanic 
groups, while black males 
are admitted about 13 years 
earlier than black females. To 
all other facility types, whites 
are admitted at later ages 
(the medians for whites are in 
the mid-thirties) than are 
blacks and Hispanics (high 



twenties). In comparing sex- 
ual subgroups in these other 
facilities, males are again ad- 
mitted earlier than females. 
White males are admitted to 
all other facilities in their early 
to mid-thirties, and blacks, 
and Hispanics in their late 
twenties. White females are 
admitted in their late thirties, 
black and Hispanic females 
in their very late twenties and 
early thirties. The only major 
deviation from this pattern is 
that black females are admit- 
ted to State and county 
hospitals in their late thirties 
(an age comparable to white 
females). 

Table 9 demonstrates the 
effect of educational level on 
facility use. For each institu- 
tional type, admitted whites 
have a higher average 
education than do the other 
groups, who do not markedly 
differ from each other. Also 
note, with respect to all types 
of facilities, that those using 
mental facilities have an 
equal or higher educational 
level than do their ethnic 
groups in general (with 
blacks and whites in State 
and county hospitals being 
the only exception). Those 
using private mental hospitals 
have the highest educational 
levels of all ethnic group 
facility type combinations. 

D. Diagnostic 
Categorization 

The question that now arises 
is, "When mental health 
facilities are used by various 
ethnic groups, what are they 
used for?" For this analysis 
our attention will be limited to 
three major facility types: 
non-Federal general 
hospitals, outpatient 
psychiatric services, and 
community mental health 
centers. Our main intent is to 
compare white and nonwhite 
utilization by diagnosis, not to 
compare the facility types. 



161 



The 10 disease categories 
by which the data have been 
classified can be found as 
row titles in Table 10. Note 
that the diagnostic categories 
are those generally used 
most frequently by all facility 
types. There do appear to be 
some interactions between 
diagnostic categories and 
facility type, however. 

We first note that a larger 
portion of the community 
mental health center 
caseload is involved with 
alcohol disorders than is true 
of the other facility types. 
Second, depressive disorders 
occupy a tremendous pro- 
portion of the general 
hospital caseload in com- 
parison to the other two 
facilities. The same thing is 
true of schizophrenia. Third, 
those conditions classified as 
transient disorders and social 
maladjustment occupy a 
greater proportion of the 
caseload of outpatient 
psychiatric services than of 
the other two facility types. 
Finally, childhood disorders 
occupy a larger portion of 
the caseload of community 
mental health centers and of 
outpatient psychiatric services 
than general hospitals. 

Table 1 1 presents a series 
of ratios which help to clarify 
the diagnostic categories 
most often ascribed to the 
four racial/sexual groups. By 
using the word "ascribed," 
we are intentionally cir- 
cumventing the question of 
the accuracy of the 
diagnoses applied to mental 
patients. 

Nonwhites have the 
highest usage of outpatient 
psychiatric services and com- 
munity mental health centers. 
This is not the case in non- 
Federal general hospitals, 
where the disparity between 
the racial groups is slightly in 
the opposite direction. 



The first disease category, 
alcohol disorders, is a male- 
dominated disease. Alcohol 
disorder rates are three to 
four times higher for males 
than for females, although 
that ratio drops down to two 
to three times more males 
than females in general 
hospitals. In comparing the 
two racial groups, note that 
this category is used more by 
nonwhites, except in non- 
Federal general hospital 
discharges. Comparing non- 
white males to white males 
and nonwhite females to 
white females, we find once 
again that it is a condition for 
which nonwhites are diag- 
nosed at higher rates than 
are whites in both sex 
groups, with the exception of 
males in general hospitals. 

Missing data make it dif- 
ficult to complete full analysis 
of drug disorders. Generally 
speaking, it is a male- 
dominated disease and it is 
also a nonwhite disease, with 
outpatient psychiatric service 
ascription of that diagnosis 
for nonwhite males almost 
seven times that for white 
males and over eight times 
that for white females. 

With respect to organic 
brain syndromes, we note 
that non-Federal general 
hospitals are used consistent- 
ly less frequently for this 
diagnostic category by non- 
whites than by whites. This is 
also a category in which 
males appear to dominate 
ascription, but the differential 
between the sexes is slight. It 
is, however, also more of an 
ethnic minority disease 
category in those patients 
seen by outpatient psychiatric 
and community mental health 
centers. 

Depressive disorders is a 
female dominated mental 
health category. It is also a 
category in which services 
are used less frequently by 
nonwhite males than by white 
males. Among females, 



however, it appears that non- 
whites have a greater utiliza- 
tion rate, at least in outpatient 
psychiatric services and com- 
munity mental health centers. 

The literature is replete 
with discussions of how 
schizophrenia is a nonwhite 
disease. In particular, it is a 
diagnostic category that is 
ascribed at very high rates to 
blacks. This disease category 
particularly seems to be one 
whose nonwhite victims 
gravitate to community men- 
tal health centers. At this 
facility type, all of the non- 
white ratios of the various 
race/sex comparisons are 
over two. The nonwhite 
female ratios are also over 
two at outpatient psychiatric 
clinics. 

Neuroses are a female- 
and white-dominated 
diagnostic category. The only 
comparison for which the 
ratios are higher for non- 
whites is the nonwhite female 
to white male comparison, 
which appears to show the 
sexual domination rather than 
the ethnic one. 

Personality disorders is a 
category ascribed more often 
to white facility users than to 
nonwhites, and it also ap- 
pears to be one in which 
there is a bit of male 
dominance. The male 
dominance appears to be 
stronger among nonwhites 
than among whites where the 
dominance is marginal. 

Although transient dis- 
orders seem to be ascribed 
more often to nonwhites than 
whites, there are not the 
strong differences associated 
with some other diagnostic 
categories. Conditions in this 
category seem to be more 
frequently ascribed to 
females than to males. 

Childhood disorders also 
appear to be something of a 
nonwhite diagnostic category, 
with most of the ratios in this 
table being above, and 
sometimes substantially 



above, one. It also appears 
to be male dominated. 

Finally, social maladjust- 
ment appears to be a non- 
white and female-dominated 
ascription, but further analysis 
shows that the heavy non- 
white female ascription masks 
the fact the nonwhite male 
ascription lags behind that of 
white males. Again, the ratios 
do not reach the high peaks 
that they do with some of the 
other diagnostic categories. 

Table 10 shows that 
depressive disorders and 
schizophrenia are the two 
most frequently used 
categories at all three facility 
types. Nonwhite female 
utilization seems to dominate 
in both of these diagnostic 
categories. 

Both nonwhite sexes have 
schizophrenia ascribed to 
them with much greater fre- 
quency than their numbers in 
the population would imply. 
A tremendous amount of 
health system literature ex- 
amines why this is the case. 
In 1982, the Institute of 
Medicine of the National 
Academy of Sciences con- 
ducted a conference on 
behavior, health risks, and 
social disadvantage. The 
mental health section of the 
Conference Report contained 
a number of papers devoted 
to the apparent high utiliza- 
tion of this diagnostic 
category with respect to 
blacks and other minorities 
(5). 

The papers' explanations 
for the higher ascription of 
this diagnostic category to 
nonwhites are multiple. First, 
it is argued that 
schizophrenia is a multiple 
disease category, and by us- 
ing one word to describe all 
those diseases, we are gloss- 
ing over some of the real dif- 
ferences between racial 
groups. Second, the 
phenomenon is attributed to 
the larger amounts of stress 
encountered by ethnic 



162 



Figure 1 

Graphic analysis of the relation between the changes* in the suicide rate 
and changes* in the unemployment rate, United States, 1905-1976 



Scaled 
Differencet 



- 2 



1970 




'Changes: Three-year arithmetic differences 

fScaled Difference: Both series are scaled for viewing such that the greatest 
amplitude from the arithmetic mean of each series, which is set equal to zero, has 
been normalized to within the range of + 4.00 if positive, or - 4.00 if negative. 

Source: M. Harvey Brenner, Ph.D., Mental Illness and the Economy. In Behavior, Health 

Risks, and Social Disadvantage. National Academy Press, 1982. 



minorities. A third explanation 
is that schizophrenia is 
related to birth injuries due to 
poor prenatal care. Other ex- 
planations attribute the 
phenomenon to: greater in- 
cidence of malnutrition 
among nonwhites; infection; 
greater prenatal maternal 
stress; and biased diagnoses. 
This latter rationale has 
received considerable atten- 
tion, as reported earlier in 
this chapter. 

Strass, however, points 
out that schizophrenia is real- 
ly a disease category of the 
lower social classes, and that 
racially disadvantaged 
groups get the disease by 
virtue of their social class 
rather than their racial group. 
He points out: 

Almost without exception, 
epidemiologic studies 
show that schizophrenia 
has a higher incidence 
and prevalence rate in the 
lower social classes. Fur- 
thermore, the pattern of in- 
crease in the lower social 
classes may shift with 
community size. The 
larger the community, the 
more marked the increase 
of schizophrenia in the 
lowest social classes ap- 
pears to be. 
Later in the paper, he states 
his rationale: 

There is a greater fre- 
quency of stresses in the 
social classes that may 
contribute. Persons from 
lower social classes may 
have more limited coping 
mechanisms because of 
restricted options available 
to them for dealing with 
complex and difficult life 
situations. And there are 
fewer treatment resources 
for the lowest social 
classes. Hollingshead and 
Redlich, as well as others, 
have showed the relative 
lack of treatment facilities 
for the lower classes. 
Those limitations, perhaps 
somewhat ameliorated, still 
continue (6). 



M. Harvey Brenner, an 
economist, has done a series 
of statistical analyses on 
economic patterns and their 
relationship to various 
disease categories. He states 
that: 

. . . multiple regression 
time series equations were 
developed which ex- 
pressed the joint influence 
of economic growth, 
recessions (measured by 
the unemployment rate), 
and inflation on national 
mortality rates (total mor- 
tality by age, sex, and 
race, cardiovascular mor- 
tality, cirrhosis of the liver, 
suicide, homicide), mental 
hospitalization and im- 
prisonment. In nearly all 
cases it was found that 
long term economic 
growth showed a highly 
beneficial effect, while 
recession increased all of 
these sources of mortality 
and psychopathology 
within a five year 
distributed lag period (7). 
Figure 1 shows Brenner's 
analysis of the relationship 
between changes in the 
suicide rate and changes in 
the unemployment rate in the 
United States between 1905 
and 1976. It is very difficult to 
ignore the high relationship 
that is demonstrated. It is 
also hard to ignore Brenner's 
assertion that this type of 
analysis has not only been 
duplicated at national, State, 
and city levels in the United 
States, but also in other 
western industrialized 
countries. 

Kramer applies statistical 
analysis. He asserts that the 
problems are much worse 
than they appear because of 
the shorter life span or higher 
mortality rates of nonwhites. 
He argues that if these kinds 
of differentials of life span 
(and therefore greater ex- 
posure to disease) are taken 
into account, the racial dif- 
ferentials in schizophrenia are 
really much larger than they 
appear to be (8). 



Thus, on the one hand 
are the social apologists who 
argue that the racial differen- 
tials in schizophrenia in- 
cidence come from biased 
diagnoses, and on the other 
hand are the statistical 
apologists who relate the 
elevated incidence and 
prevalence rates of 
schizophrenia to social and 
economic factors. Perhaps 
the determination of which of 
these positions is correct re- 
quires considerable additional 
study. This point of view was 
summarized by Williams, who 
states: 

In a series of community 
wide studies of 
psychological distress 
published in the 1970's by 
Warheit, llfeld, Comstock, 
and Quesada, the authors 
found no relationship be- 
tween race and mental ill- 
ness that was not 
explained by 



socioeconomic status. 
However, socioeconomic 
status explains no more 
than 14 percent of the 
variance in those Afro- 
American populations that 
were studied. While more 
unbiased than previous 
studies, the literature sug- 
gests that responses to 
community-wide surveys is 
again influenced by class, 
race, and sex of the 
respondent and inter- 
viewer. Clearly the ac- 
curate measurement of 
psychological distress in 
minority and disadvan- 
taged populations has yet 
to be achieved. This is 
particularly true of the 
measurement of 
psychological distress in 
minority male populations 
0). 



163 



E. Mental Disorders 
among Native 
Americans 

Mental disorders are a major 
and growing cause for 
hospitalizations in Indian 
Health Service Hospitals and 
that Service's contract 
hospitals. Table 12 presents 
the total number of 
discharges and total hospital 
days due to mental disorders 
for fiscal years 1967 through 
1972. In 1967, mental 
disorders were the ninth 
leading cause of hospitaliza- 
tions. From 1967 to 1972, 
however, the number of 
discharges in the mental 
disorder category nearly 
doubled, and by 1972, this 
category ranked sixth. 
Hospital days associated with 
mental disorders also more 
than doubled during this 
period. 

Table 13 lists the 15 
leading causes of outpatient 
visits by diagnostic classifica- 
tion for the Indian Health 
Service's facilities. In 1976, 
mental disorders constituted 
2 percent and were the 14th 
leading reason for outpatient 
visits. Table 14 lists the 10 
leading causes for inpatient 
care in Indian Health Service 
contract hospitals in the same 
year. In the 4 years since the 
tabulation reported in Table 
12, mental disorders have 
moved up to the fifth most 
freguent cause for 
hospitalization, constituting a 
little over 6.5 percent of all 
hospitalizations. At this rate of 
growth they could very well 
soon become the fourth 
leading cause of hospitaliza- 
tion, if this has not happened 
already. Data do not appear 
to be available which break 
down all of the causes. 

The Indian Health Service 
discharge summary for 1967 
to 1972 has indicated that 
the upward trend in the 



number of patients hospital- 
ized with mental disorders 
reflects the attempts of the In- 
dian Health Service to deal 
with mental health problems 
in this population. This in- 
creased mental health service 
to the Indian and Alaska 
Native population has been 
facilitated by the change in 
their attitude towards mental 
disorders, including 
alcoholism. Native Americans 
have become less resistant to 
seeking outside help for men- 
tal problems and disorders. 

Alcoholism is one of the 
most serious health problems 
facing the Indian people. The 
death rate from alcoholism 
for Indians and Alaska 
Natives during the past few 
years has ranged from 4.3 to 
5.5 times that in the United 
States for all races. 
Alcoholism death rates for In- 
dians and Alaska Natives are 
given in Table 15. The death 
rate from alcoholism has 
more than doubled from 
1966 to 1975, although there 
appear to be only some 
minor variations in the death 
rate from alcoholic psychosis. 
From the beginning to the 
end of this time period, there 
has been a 32 percent in- 
crease in deaths from cir- 
rhosis of the liver with men- 
tion of alcoholism. In 1975, 
the alcoholism death rate 
declined slightly below the 
rates experienced in 1973 
and 1974. This probably 
reflected the beginning of a 
trend. From the following 
data, we can see that in the 
11 -year period from 1971 to 
1982, discharge rates for 
alcoholism almost halved 
among the Indians and 
Alaska Natives. The differen- 
tial with the total U.S. popula- 



tion dropped drastically from 
7.08 to 1.67. 

Table 16 contains data 
breakdowns by diagnostic 
category of Indian Health 
Service hospitalizations from 
1967 to 1972. Although over 
this 6-year period the most 
striking pattern was the 1 1 
percent increase in 
hospitalizations with 
diagnoses of alcoholism and 
drug dependence, the other 
changes could have been 
due to the constraints of the 
degrees of freedom in using 
percentages (that is, there is 
only 100 percent to distribute 
among the categories, and if 
one category experiences an 
increased percentage, other 
categories of necessity must 
end up with decreased 
percentages, even though 
their rares may not have 
changed). 

The following text table 
shows data that compare 
rates for the end of that 
6-year period with a recent 
year. Note that alcoholism 
discharge rates over the 
9-year period for all U.S. 
races "U.S. All Races CY 
1971" compared with "U.S. 
Short-Stay CY 1980" more 
than doubled, while over the 
11 -year period 1971 to 1982 
the Indian and Alaska Native 
rates almost halved. The lat- 
ter effect is probably due to 
the efforts of the Indian 
Health Service to deal with 
this problem. To the extent 
that these data are valid for 
comparative uses of this sort, 
the American Native to "All 
U.S. Races" ratio decreased 
from 7.08 to 1.67 over this 



period. Note also the 11.3 
percent decrease in 
discharges for nonorganic 
psychoses, and the 71.0 per- 
cent decrease in discharges 
for neuroses and personality 
disorders. 

The other outstanding 
trend appears to be related 
to sex. There has been an in- 
crease of approximately 30 
percent in the male-to-female 
sex ratio in admissions over 
the 6 years from 1 967 to 
1972. Almost all of this ap- 
parent increase seems to be 
related to the alcoholism 
category. By 1972, males 
outnumbered females in such 
admissions by 3 to 1 . 

Two other mental health 
statistics can be used to ar- 
rive at some index of the 
mental health problems 
associated with Native 
Americans: deaths from 
suicide and deaths from 
homicide. Tabulations of rele- 
vant data can be found in 
Tables 17 and 18, 
respectively. In the 17-year 
period from 1959 to 1975, 
there has been a change in 
the ratio of Indian to non- 
Indian suicides. The ratio 
decreased somewhat from 
1959 to 1965, at which time 
there was almost a parity be- 
tween the two ethnic groups, 
but a return to the high rate 
started in 1966 and con- 
tinued through 1975, at 
which time the ratio went 
above 2 to 1 . 



164 



Number of discharges and discharge rate 1 for mental 
disorders, Indians and Alaska Natives and U.S. All Races. 



IHS & 
Contract 
FY 1982 



U.S. Short- 
Stay 
CY 1980 



IHS & 
Contract 
FY 1971 



U.S. 
All Races 
CY 1971 









Number 








Number 






Number 


Rate 


(1,000s) 


Rate 


Number 


Rate 


(1,000s) 


Rate 


Total 


4,954 


63.1 


1,692 


75.8 


5,310 


115.4 


1,050 


51.9 


Alcoholism 


3,194 


40.7 


543 


24.3 


3,386 


73.6 


210 


10.4 


Psychoses 


496 


6.3 


393 


17.6 


329 


7.1 


220 


10.9 


(non-organic) 


















Neuroses and 


509 


6.5 


335 


15.0 


1,030 


22.4 


405 


20.0 


personality disorders 


















All other 


755 


9.6 


421 


18.9 


565 


12.3 


215 


10.6 



'Number of discharges per 10,000 population 



Source: IHS and Contract General Hospitals: Annual Reports 2C and 
31. U.S. Short-stay Hospitals: National Center for Health Statistics, 
DHHS unpublished data. In FY 1984 Budget Appropriation. Indian 
Health Service 'chart series' tables. Office of Program Statistics, Division 
of Resource Coordination, Indian Health Service, Rockville, MD. April 
1983. 



There was a similar 
decline in homicide deaths, 
starting precipitously in 1965, 
when the ratio went down 
from 4 to 1 to 3 to 1 (Indian 
to non-Indian). The rate then 
continued to decline for the 
next 2 years but seems to 
show only minor nondirec- 
tional variations through the 
rest of the period. The most 
recent data indicate that a 
modest decline may still be 
taking place. 

F. Drug Abuse 

With respect to health status, 
drug use is extremely difficult 
to analyze. On the one hand, 
there is reason to believe that 
a very large amount of 
"unauthorized" use of licit 
drugs occurs in this country. 
(By "drug" we mean any 



substance that has a phar- 
macological effect, and by 
"unauthorized" we mean that 
a health care professional did 
not suggest, advise, or 
prescribe the substance as a 
regimen of therapy.) On the 
other hand, there is also 
reason to believe that a large 
amount of use of illicit drugs 
occurs. 

Two questions need to be 
answered before we can 
analyze this problem: (a) At 
what point does substance 
use become substance 
abuse? (b) With which 
substances should we be 
concerned? The answer most 
frequently given to the latter 
question seems to focus on 
addictive drugs (with the ex- 
ception of nicotine), but since 



our interest is in health status, 
we should not limit our atten- 
tion to such a definition. 
Some of the mostly widely 
used/abused drugs that may 
be having some effect on 
health status (e.g., Valium, 
Darvon, Percodan, Elavil, 
Melaril) do not get the atten- 
tion that the illegal drugs do, 
and thus there are insufficient 
data available to characterize 
abusage patterns. Regret- 
tably, we are forced to limit 
our analytic attention to il- 
legal, addictive drugs. But 
even here we are limited to 
those persons who use/abuse 
these drugs such that they 
present themselves for treat- 
ment at some health care 
facility. We have reason to 
know that the use/abuse of 
these drugs far outpaces 
whatever amount is brought 
to the attention of the health 
care delivery system. (This is 
particularly true of marijuana 
and cocaine, which in many 
quarters are socially if not 
legally sanctioned.) 

As to delineation between 
use and abuse, we are 
equally impeded in our 
analysis. Were we to define 
abuse as occurring when the 
effects of a single administra- 
tion or a pattern of usage 
lead to health problems, we 
would again be limited in our 
analysis because abuse at 
this level is not measured. 
We must understand, 
therefore, that the following 
discussion is very limited, 
since it considers only illegal 
drugs and only usage levels 
that require treatment. 

The proportions of patients 
receiving drug abuse treat- 
ment services in 1976 at 



reporting clinics are 
presented in Figure 2, 
broken down by the 
racial/ethnic groups that are 
tallied separately. Also 
presented are comparative 
proportions of the representa- 
tion of those groups in the 
general population. From that 
figure, it can be seen that 
black, Puerto Rican, and 
Mexican-American groups 
are over-represented among 
the clinic clients, American In- 
dians and Cubans are 
represented proportionally to 
their numbers in the popula- 
tion, and the white and Asian 
groups are under-represented. 

The predominant drug 
problem for clients under 18 
years of age was marijuana. 
With respect to ethnic/racial 
groups, white clients were 
less likely to be opiate 
abusers than black or 
Hispanic clients, regardless 
of sex. For white, Hispanic, 
and black clients, the mean 
ages of first use of a primary 
drug were 18.7, 18.1 and 
20.9 years. Black clients 
were less likely than either 
Hispanic or white clients to 
seek treatment during the first 
3 years of continuing use of 
their primary drug. The time 
interval between the first use 
and first continuing use of a 
primary drug was less than 
1 year for 58.9 percent of all 
clients. Table 19 presents a 
breakdown of drug clinic 
utilization for 1975 and the 
first two quarters of 1976. 
Utilization rates for "Other" 
seem to be relatively con- 
stant, the rates for whites 
seem to be decreasing, while 
the rates for blacks and 
Hispanics seem to be on the 
rise (see the discussion on 
degrees of freedom, above, 
related to the entries in Table 
16). 



165 



Figure 2 

Utilization of federally funded drug abuse clinics by Racial/Ethnic Group. 

Percent Drug Clinic Clients 
IH Approximate Percent in Population 

Percentage Use 

0 20 40 60 80 100 



White* 



Black 



American 
Indian 



Asian 



Puerto Rican 



Mexican 
American 



Cuban 



'Includes: Central American, South American and Other Hispanics 

Source: National Institute of Drug Abuse — Clinic Oriented Data Acquisition 
Project, 1976 



Drug clinic utilization dur- 
ing the same six-quarter 
period in 1975 and 1976 has 
been disaggregated in Table 
20 by the four main drug 
groups used by clinic pa- 
tients. The overall trend in 
total clients is for increased 
utilization from opiate abusers 
and decreased utilization 
from marijuana abusers. The 
number of clients using bar- 
biturates and amphetamines 
was relatively constant. The 
relative proportion of black 
opiate abusers was about 
four times their proportion in 
the general population, but 
their proportion in the abus- 
ing population appears to 
have been on a slight 
downward trend. Hispanic 
opiate abusers used the 
clinics in increasing propor- 
tions, even though their rate 
was already almost three 
times their proportion in the 
general population. 

Marijuana abuse patterns 
do not seem to have been 
very dynamic, and the clinic 
usage patterns show blacks 
with rates about one and a 
half, and Hispanics with rates 
about twice their representa- 
tion in the general 
population. 

The racial/ethnic groups 
use clinic services for bar- 
biturates and amphetamines 
in almost the exact propor- 
tions they represent in the 
general population. There 
does seem to be an upward 
trend for Hispanics using 
clinics for both of these 
drugs, and a similar upward 
trend for blacks using am- 
phetamines. The decreasing 
proportion of white usage for 
both of these drugs repre- 
sented a real decrease, and 
not just an offset, since use 
of these drugs was at least 
stable and probably slightly 
increasing. 



Although we have already 
observed that the rates of 
abuse are not necessarily 
reflected in clinical services 
utilization, the rates may be 
an accurate indication of the 
actual patterns of drug abuse 
by drug and racial/ethnic 
categories. 

As indicated previously, 
drug abuse starts early in life. 
It may be possible to predict 
future trends by examining 
usage rates of youths. To this 
end, the Institute for Social 
Research of the University of 
Michigan has been measur- 
ing high school seniors' drug 
abuse rates in 16,000 to 
17,000 students across the 



Nation during the last 5 
years. They have detected a 
constant downward trend. 
From 1979 to 1983, they 
noted a 10 percent reduc- 
tion, from 37 to 27 percent, 
of those who had used mari- 
juana during the month prior 
to the survey. Daily users 
dropped from 10.3 percent 
to 5.5 percent during the 
same period. 

During 1982 and 1983, 
they also measured the 
following decreases in self- 
reported drug abuse: LSD 
dropped from 3 to 2 percent; 
cocaine dropped from 6 to 5 
percent; stimulants from 16 to 
12 percent; and sedatives 



from 5 to 3 percent. 

The proportion of seniors 
who had taken five or more 
drinks in a row during the 2 
weeks prior to the survey re- 
mained at 41 percent during 
1982-1983, although those 
who had used liquor in any 
way in the previous month 
dropped from 71 to 69 per- 
cent in the 1982-1983 com- 
parisons, and daily users 
dropped from 6 to 5.5 per- 
cent. It appears that the cur- 
rent adolescent generation 
may not be getting "turned 
on" by the use of alcohol 
and drugs at the same rates 
as the immediately preceding 
generation. But when they do 
use alcohol, they appear to 
be using it in excess (10, p. 
3). 



166 



Table 1 

Mental health services by service mode, 1970-80. 



Percent Increase 

Type of services 1970 1972 1974 1976 1978 1980 During Period 

All facilities 3,005 3,187 3,315 3,480 3,738 3,727 24.0 

Inpatient services 1,734 1,913 2,060 2,273 2,421 2,526 45.7 

Outpatient services 2,156 2,271 2,219 2,318 2,429 2,431 12.8 

Day treatment 778 981 1,281 1,447 1,571 1,648 111.8 



Source: Mental Health, United States 1983, National Institute of Mental Health. Mental Health, United States 1983, Taube, C.A., 
and Barrett, S.A., eds DHHS Pub No (ADM) 83-1275. Rockville, MD: the Institute, 1983. pp. 10-13. 



167 



Number of inpatient additions, outpatient additions, and day treatment additions by type of mental health facility: United States, selected 
years, 1969-79. 



Type of facility 


1969 


1971 


1973 


1975 


1977 


1979 








Number of inpatient additions 






All facilities 


1,282,698 


1 ,336,418 


1,415,012 


1,556,978 


1,584,672 


1,541,659 


State and county mental hospitals . 


486,661 


474,923 


442,530 


433,529 


414,703 


383,323 


rllvcut; (JoyUI lldll I lUoJJIlcuo 


Z)C- , UJU 


87 1 Dfi 


109,516 


125,529 


1 88 1 R1 


1 4(~l 881 
I ^fU,oo I 


Non-Federal general hospital 














psychiatric services 


478,000 


519,926 


468,415 


543,731 


551,190 


551,190 


V.A. psychiatric services 


135,217 


134,065 


169,106 


180,701 


180,416 


180,416 


Federally funded community 














mental health centers 


59,730 


75,900 


183,026 


236,226 


257,347 


246,409 


Residential treatment centers for 














emotionally disturbed children . . . 


7,596 


11,148 


12,179 


12,022 


15,152 


15,453 


All other facilities 


23,438 


33,350 


30,240 


25,240 


27,713 


24,037 








Number of outpatient additions 






All facilities 


1 ,146,612 


1 ,378,822 


1,714,030 


2,289,779 


2,343,360 


2,634,727 


State and county mental hospitals . 


164,232 


129,133 


167,647 


146,078 


107,692 


81 ,919 


Private psychiatric hospitals 


25,540 


18,250 


31,656 


32,879 


33,573 


30,004 


Non-Federal general hospital 














[Joy Of lldu IO ocl VILco 


1 70. SSft 


989 677 


238,208 


254,665 


994 984 


994 9R4 


V.A. psychiatric services 


16,790 


51,645 


68,016 


93,935 


120,243 


120,243 


Federally funded community 














mental health centers 


176,659 


335,648 


486,585 


784,638 


876,121 


1,222,305 


Residential treatment centers for 














emotionally disturbed children . . . 


7,920 


10,156 


10,993 


19,784 


18,155 


19,653 


Freestanding psychiatric outpatient 














clinics 


538,426 


484,677 


650,034 


870,649 


861,411 


825,046 


All other facilities 


46,487 


66,636 


60,891 


87,151 


101,881 


111,273 








Number of day treatment additions 






All facilities 


55,486 


75,545 


128,949 


163,326 


170,591 


172,331 


State and county mental hospitals . 


10,505 


16,554 


16,793 


14,205 


10,697 


9,808 


Private psychiatric hospitals 


2,872 


1 ,894 


2,920 


3,165 


3,842 


3,467 


Non-Federal general hospital 














psychiatric services 


1 8,094 


1 1 ,563 


18,772 


14,216 


1 2,724 


HO 70,1 

12/24 


V.A. psychiatric services 


3,500 


4,023 


7,049 


7,788 


6,978 


6,978 


Federally funded community 














mental health centers 


13,011 


21,092 


59,130 


94,092 


102,493 


98,332 


Residential treatment centers for 














emotionally disturbed children . . . 


671 


994 


1,666 


3,431 


3,147 


2,519 


Freestanding psychiatric 














outpatient clinics 


4,387 


10,642 


15,329 


21,928 


21,149 


29,587 


All other facilities 


2,446 


8,783 


7,300 


4,501 


9,561 


8,916 



Source: Compiled and abstracted by CHESS from Mental Health, United States 1983. National Institute of Mental Health. Mental 
Health, United States 1983, Taube, C A , and Barrett, S.A., eds. DHHS Pub. No (ADM) 83-1275. Rockville, MD: the Institute. 1983 
p. 17, 27, and 29. 



168 



Table 3 

Number of resident patients, total admissions, net releases, and deaths, State and county mental hospitals: United States, 1950-80. 



Number of Resident patients Net 



Year 


hospitals 


at end of year 


Admissions 1 


roll \ t\i " , ■ 


Additions 2 


Discontinuations 4 


Deaths 4 


i you 


^99 




1 59 986 


QQ 659 


N.A. 


Nl A 

1 N .r\. 


41 980 


1951 


322 


520,326 


152,079 


101,802 


N.A. 


N.A. 


42,107 


1952 


329 


531,981 


162,908 


107,647 


N.A. 


N.A. 


44,303 


1953 


332 


545,045 


170,621 


113,959 


N.A. 


N.A. 


45,087 


1954 


352 


553,979 


171,682 


118,775 


N.A. 


N.A. 


42,652 


1955 


275 


558,922 


178,003 


126,498 


N.A. 


N.A. 


44,384 


1956 


278 


551,390 


185,597 


145,313 


N.A. 


N.A. 


48,236 


1957 


277 


548,626 


194,497 


150,413 


N.A. 


N.A. 


46,848 


1958 


278 


545,182 


209,823 


161,884 


N.A. 


N.A. 


51,383 


1959 


279 


541,883 


222,791 


176,411 


N.A. 


N.A. 


49,647 




980 


535 540 


984 7Q1 


1 99 R1R 


N.A. 


N A 


49 748 


1961 


285 


527,456 


252,742 


215,595 


N.A. 


N.A. 


46,880 


1962 


285 


515,640 


269,854 


230,158 


N.A. 


N.A. 


49,563 


1963 


284 


504,604 


283,591 


245,745 


N.A. 


N.A. 


49,052 


1964 


289 


490,449 


299,561 


268,616 


N.A. 


N.A. 


44,824 


1965 


290 


475,202 


316,664 


288,397 


N.A. 


N.A. 


43,964 


1966 


298 


452,089 


328,564 


310,370 


N.A. 


N.A. 


42,753 


1967 


307 


426,309 


345,673 


332,549 


N.A. 


N.A. 


39,608 


1968 


312 


399,152 


367,461 


354,996 


N.A. 


N.A. 


39,677 


1969 


314 


369,969 


374,771 


367,992 


N.A. 


N.A. 


35,962 


1 Q70 


31 5 


337 61 9 


'384 511 


386 Q37 


N.A. 


N A 


30 804 


1 Q71 




308 Q83 


409 479 


4.DS 601 


474 Q98 


\J\J I , ! C-\J 


PR 


1972 


327 


274,837 


390,455 


405,348 


460,443 


472,282 


23,282 


1973 


334 


248,518 


377,020 


387,107 


442,530 


454,719 


19,899 


1974 


323 


215,573 


374,554 


389,179 


434,345 


448,203 


16,597 


1975 


313 


193,436 


376,156 


384,520 


433,529 


442,096 


13,401 


1976 


300 


170,619 


N.A. 


N.A. 


413,559 


421,461 


10,922 


1977* 


298 


159,523 


N.A. 


N.A. 


414,703 


415,314 


9,716 


1978* 


284 


153,544 


N.A. 


N.A. 


406,407 


404,031 


9,080 


1979* 


280 


145,616 


N.A. 


N.A. 


406,259 


404,031 


7,830 


1980* 


275 


137,810 


N A 


N.A. 


398,451 


395 165 


7,108 



1 From 1950-1975 the NIMH collected information on inpatient admissions (admissions and readmissions) to State and county men- 
tal hospitals. Beginning in 1976 only information on number of additions is available. 

2 From 1 971 to the present NIMH has collected information on inpatient additions to State and county mental hospitals on its annual 
Inventory of Mental Health Facilities. Additions differ from admissions because returns from leave are included as well as admis- 
sions and readmissions. 

3 For all years net releases were obtained by summing the resident patients at the beginning of the year and admissions and sub- 
tracting from the sum deaths and resident patients at the end of the year 

4 The ratio of net releases to admissions is an indication of whether the patient population is increasing or decreasing. A ratio more 
than 1 indicates a decreasing patient population: a ratio less than one an increasing population. Subsequent to 1975. a measure 
of gam or loss of patient population is the ratio of discontinuations plus deaths to additions. If this ratio is less than 1 , the patient 
population is increasing; if it is greater than one the patient population is decreasing 
"Unpublished provisional estimates for 1977, 1978. and 1979 
N.A. Not available. 
Sources of data: 

1) 1950-1955 and 1960-1964: NIMH, Patients in Mental Institutions. 

2) 1956-1959, NIMH Mental Health Statistics, Current Reports, Table A (Series MHB-H-7. January. 1963) 

3) 1965-1973: NIMH, Statistical Note 112, Table 1: Resident Patients End of Year. 

4) 1965-1966 NIMH, Mental Health Statistics, Current Facility Reports, Table 4, Provisional Patient Movement and Administrative 
Data, State and County Mental Hospitals. U.S., July 1, 1968-June 30, 1969 

5) 1967-1968: NIMH, Statistical Note 60, Table 5, Admissions. 

6) 1969: NIMH, Statistical Note 77, Table 5, Admissions. 

7) 1 970-1 973: NIMH Statistical Note 1 06, Table 4, Admissions. Deaths, NIMH Current Facility Reports or Statistical Notes show- 
ing Provisional Data for State and County Mental Hospitals for each respective year. 

8) 1965-1973 

9) 1974: NIMH, Statistical Note 114. Table 1. 

10) 1975: NIMH. Statistical Note 132. Table 1 

11) 1976: NIMH, Statistical Note 153, Table 4. 

12) 1977-1979 Unpublished provisional estimates from the Survey and Reports Branch, Division of Biometry and Epidemiology, 
National Institute of Mental Health 



169 



Table 4 

Distribution of additions to federally funded community mental health centers by age, sex, and race, United States, 1978 



Race 



Sex and age 


Total 


White 


All other races 


Total 


White 


All other races 






Number 






Percent 




Both sexes 














Total 


1,180,800 


946,945 


233,855 


100.0% 


100.0% 


100.0% 


Under 15 


184,128 


144,009 


40,119 


15.6 


15.2 


17.1 


15-17 


84,430 


67,918 


16,512 


7.1 


7.2 


7.1 


18-24 


221,928 


174,692 


47,236 


18.8 


18.5 


20.2 


25-44 


461,528 


370,577 


90,951 


39.1 


39.1 


38.9 


45-64 


178,423 


148,120 


30,303 


15.1 


15.6 


13.0 


65+ 


50,363 


41,629 


8,734 


4.3 


4.4 


3.7 


Males 














Total 


582,225 


462,262 


119,963 


100.0% 


100.0% 


100.0% 


Under 15 


111,216 


86,745 


24,471 


19.1 


18.8 


20.4 


15-17 


43,009 


34,452 


8,557 


7.4 


7.4 


7.1 


18-24 


106,739 


82,661 


24,078 


18.3 


17.9 


20.1 


25-44 


214,337 


169,570 


44,767 


36.8 


36.7 


37.3 


45-64 


85,559 


71,252 


14,307 


14.7 


15.4 


11.9 


65+ 


21,365 


17,582 


3,783 


3.7 


3.8 


3.2 


Females 














Total 


598,575 


484,683 


113,892 


100.0% 


100.0% 


100.0% 


Under 15 


72,912 


57,264 


15,648 


12.2 


11.8 


13.7 


15-17 


41,421 


33,466 


7,955 


6.9 


6.9 


7.0 


18-24 


115,189 


92,031 


23,158 


19.2 


19.0 


20.3 


25-44 


247,191 


201,007 


46,184 


41.4 


41.4 


40.7 


45-64 


92,864 


76,868 


15,996 


15.5 


15.9 


14.0 


65+ 


29,998 


24,047 


4,951 


4.8 


5.0 


4.3 



Source: Division of Biometry and Epidemiology, National Institute of Mental Health, Provisional Data on Federally Funded Com- 
munity Mental Health Center 1978-1979. September 1981. Table 14, p. 17. 



Table 5 

Utilization of mental health facilities, 1975. 

Admissions* 







All races 






White 




All other races 


Type of Facility 


Total 


Male 


Female 


Total 


Male 


Female 


Total 


Male 


Female 


State & County Mental Hospital 


385,237 


248,937 


136,300 


296,151 


190,788 


105,363 


89,086 


58,149 


30,937 


(inpatient services) 


(182.2) 


(243.7) 


(124.7) 


(161.1) 


(214.2) 


(111.2) 


(321.9) 


(444.5) 


(212.0) 


Private Mental Hospital 


129,832 


55,706 


74,126 


119,356 


50,727 


68,629 


10,476 


4,979 


5,497 


(inpatient services) 


(61.4) 


(54.5) 


(67.5) 


(64.9) 


(57.0) 


(72.5) 


(37.9) 


(38.1) 


(37.7) 


Outpatient Psychiatric 


1,406,065 


634,355 


771,701 


1,171,196 


528,794 


642,402 


234,809 


105,561 


126,308 


services 


(665.0) 


(621.1) 


(706.0) 


(637.3) 


(593.8) 


(678.2) 


(848.8) 


(806.9) 


(886.3) 










Discharges* 










VA Hospital Psychiatric 


218,761 


215,640 


3,121 


179,404 


176,606 


2,798 


39,357 


39,034 


323 


inpatient units 


(103.5) 


(211.1) 


(2.9) 


(97.6) 


(198.3) 


(3.0) 


(142.2) 


(298.4) 


(2.2) 


Nonfederal general Hospital 


515,537 


211,569 


303,968 


450,992 


184,219 


226,773 


64,545 


27,350 


37,195 


psychiatric inpatient units 


(243 8) 


(207.1) 


(278.1) 


i.-'.r. , 


(206.9) 


(281.7) 


(233.3) 


(209.1) 


(254.9) 



'The top entry in each cell denotes the number of patients, the bottom entry within parentheses donates rates per 100,000 population 
Source: National Institute of Mental Health, Series CN No. 2. Characteristics of Admissions to Selected Mental Health Facilities, 
1975: An Annotated Book of Charts and Tables. DHHS Publication No. (ADM) 81-1005, Superintendent of Documents, U.S. Govern- 
ment Printing Office, Washington, DC, 1981. 



170 



Table 6 



Hispanic American admissions as a percent of total admissions by type of facility: selected mental health 


facilities. United States, 1975. 










Admissions 


nibpdiiio durTiiobiuns 






Hispanic 


do d pciooni 


i ype ui idcimy 


Total 


origin 


U! LUldl dUI I MbblUI lb 


Outpatient psychiatric services 3 .... 


1,406,065 


59,800 


4.3% 


Inpatient psychiatric services: 








State & county mental hospitals 


385,237 


13,123 


3.4 


Private mental hospitals 


129,832 


3,438 


2.6 


Non-Federal general hospitals 


515,537 


28,588 


5.5 


Public 


139,352 


14,643 


10.5 


Nonpublic 


376,185 


13,945 


3.7 



a Affiliated and freestanding outpatient psychiatric services. 

Source: National Institute of Mental Health, Series CN No. 3, Hispanic Americans and Mental Health Services: A Comparison of 
Hispanic, Black, and White Admissions to Selected Mental Health Facilities, 1 975. DHHS Publication No. (ADM) 80-1 006. Superinten- 
dent of Documents, U.S. Government Printing Office, Washington, DC, 1980. Table B, p. 2 



Table 7 



Age-adjusted admission rates per 


100,000 population by race/ethnicity and sex: selected mental health facilities, United States, 1975. 


Type of facility 


White 


Black 


Hispanic origin 






Both sexes 




Outpatient psychiatric services 3 


639.2 


814.0 (1.27)* 


528.0 (0.83) 


Inpatient psychiatric services: 
State & county mental hospitals 

Private mental hospitals 

Non-Federal general hospitals 

Public 

Nonpublic 


159.7 

64.4 

243.3 

60.9 

182.4 


367.5 (2.30) 
40.6 (0.63) 

258.9 (1.06) 

110.6 (1.82) 
148.3 (0.81) 

Male 


123.9 (0.78) 
37.4 (0.58) 
271.6 (1.12) 
133.6 (2.19) 
138.1 (0.76) 


Outpatient psychiatric services 3 


587.7 


729.7 (1.24) 


499.7 (0.85) 


Inpatient psychiatric services: 
State & county mental hospitals 

Private mental hospitals 

Non-Federal general hospitals 

Public 

Nonpublic 


213.2 

56.9 

206.4 

64.0 

142.4 


509.8 (2.39) 
41.3 (0.73) 
237.3 (1.15) 

122.1 (1.91) 

156.2 (1.10) 

Female 


193.6 (0.91) 
39.2 (0.69) 
256.4 (1.24) 
148.0 (2.31) 
108.4 (0.76) 


Outpatient psychiatric services 3 


682.7 


865.9 (1.27) 


553.2 (0.81) 


Inpatient psychiatric services: 
State & county mental hospitals 

Private mental hospitals 

Non-Federal general hospitals 

Public 

Nonpublic 


110.0 

71.3 

277.9 

57.7 

220.1 


248.4 (2.59) 
40.0 (0.56) 

277.5 (1.00) 

101.2 (1.75) 

176.3 (0.80) 


60.8 (0.55) 

35.9 (0.50) 
283.4 (1.02) 
118.6 (2.06) 
164.8 (0.75) 



a Affiliated and freestanding outpatient psychiatric services. 

'Entries in parentheses are ratios of minority facility usage to White facility usage. 

Source National Institute of Mental Health, Series CN No. 3, Hispanic Americans and Mental Health Services: A Comparison of Hispanic, Black, and White Admissions to Selected 
Mental Health Facilities, 1975. DHHS Publication No (ADM) 80-1006. Superintendent of Documents, U.S. Government Printing Office, Washington, DC, 1980. Table C. p.3. 



171 



Table 8 



Median age of admissions by sex and race/ethnicity: selected mental health facilities, United States, 1975. 




White 


Black 






excluding 


excluding 


Hispanic 


Type of facility 


Hispanic 


Hispanic 


origin 






Both sexes 




Outpatient psychiatric services 3 


28.5 


25.9 


28.7 


Inpatient psychiatric services: 








State & county mental hospitals 


35.8 


32.2 


31.2 


PriwQtp mpntpil hrmnitals 


38.3 


29.9 


32.6 


Non-Federal general hospitals 


36.3 


28.6 


28.3 


Public 


33.5 


27.5 


28.6 


Nonpublic 


37.5 


29.3 


27.7 






Male 




Outpatient psychiatric services 3 


24.7 


17.5 


24.9 


Inpatient psychiatric services: 








State & county mental hospitals 


34.6 


30.0 


31.9 


Private mental hospitals 


36.2 


28.6 


30.8 


Non-Federal general hospitals 


34.2 


27.7 


25.7 


Public 


32.4 


25.7 


25.2 


Nonpublic 


35.4 


29.2 


26.6 






Female 




Outpatient psychiatric services 3 


30.7 


30.0 


31.2 


Inpatient psychiatric services: 








State & county mental hospitals 


37.9 


38.0 


29.3 


Private mental hospitals 


39.7 


31.0 


34.9 


Non-Federal general hospitals 


37.6 


29.2 


30.7 


Public 


34.6 


29.0 


32.8 


Nonpublic 


38 4 


29 3 


28.5 


a Affiliated and freestanding outpatient psychiatric services. 








Source National Institute ot Mental Health, Series CN No. 3, 


Hispanic Americans and Mental Health Services: A Comparison of 


Hispanic, Black, and White Admissions to Selected Mental Health Facilities, 1975 DHHS Publication No (ADM) 80-1006, Superinten- 


dent of Documents, U.S. Government Printing Office, Washington, DC, 1980 


Table D, p 5. 




Table 9 








Median years of education of admissions to selected mental health facilities compared with median 


years of education of the general United States population by race/ethnicity. United States, 1975. 




White 


Black 






excluding 


excluding 


Hispanic 


Type of facility 


Hispanic 


Hispanic 


origin 


Outpatient psychiatric services 3 


12.3 


1 1.3 


11.7 


Inpatient psychiatric services: 








State & county mental hospitals 


11.7 


10.2 


10.3 


Private mental hospitals 


12.4 


12.3 


12.2 


Non-Federal general hospitals 


12.4 


11.4 


11.2 


Public 


12.3 


11.7 


10.6 


Nonpublic 


12.4 


11,3 


11.9 


United States population 13 


1 2 3 


1 1 0 


10.0 



^Affiliated and freestanding outpatient psychiatric services. 

Source: United States Bureau of the Census, Current Population Reports, Series P-20, No. 295 U.S. data for whites and blacks 
include persons of Hispanic origin 



172 



Table 10 

Diagnostic category utilization by facility type, 1975. 

Non-federal Outpatient Community 



General Psychiatric Mental Health 

Hospital Services Centers 

Disease Category Discharges Admissions Additions 

Alcohol Disorders 7.0 3.8 9.7 

Drug Disorders 3.5 1.6 3.1 

Organic Brain Syndrome 3.7 2.2 2.4 

Depressive Disorders 37.7 12.9 13.4 

Schizophrenia 24.1 10.5 10.0 

Neuroses 6.2 8.2 Not listed 

Personality Disorders 5.8 9.9 Not listed 

Transient Disorders .9 14.2 Not listed 

Childhood Disorders 5.1 10.2 13.1 

Social Maladjustment .4 10.2 7.2 

Total Percent 94.4 83.7 58.9 



Source: National Institute of Mental Health, Series CN No. 2. Characteristics of Admissions to Selected Mental Health Facilities, 
1975: An annotated book of charts and tables DHHS Pub. No. (ADM) 81-1005, Superintendent of Documents, U.S. Government 
Printing Office, Washington, DC, 1981 Table 5D, p. 59, Table 5E, p. 60, Table 4F, p 54 



Table 11 



Facility utilization by diagnosis, 1975 





Non-federal 


Outpatient 


Community 




General 


Psychiatric 


Mental Health 




Hospital 


Services 


Centers 


Ratios 


Discharges 


Admissions 


Additions 


A. Nonwhite to White Utilization 


.95 


1.33 


1.37 


B. Alcohol Disorders 








Total Nonwhite to total White 


.95 


1.74 


1.36 


Nonwhite males to Nonwhite females 


2.21 


3.81 


3.71 


White males to White females 


2.89 


3.31 


3.80 


Nonwhite males to White males 


.91 


2.09 


1.37 


Nonwhite males to White females 


2.63 


.63 


5.21 


Nonwhite females to White males 


,41 


.49 


.37 


Nowhite females to White females 


1.19 


1.58 


1.40 


C. Drug Disorders 








Total Nonwhite to total White 


1.10 


4.61 


1.14 


Nonwhite males to Nonwhite females 






2.18 


White males to White females 


.92 


1.18 


2.01 


Nonwhite males to White males 




6.88 


1.59 


Nonwhite males to White females 




8.15 


3.2 


Nonwhite females to White males 


1.60 




.73 


Nonwhite females to White females 


1.48 




1.47 


D. Organic Brain Syndromes 








Total Nonwhite to total White 


.72 


1.47 


1.77 


Nonwhite males to Nonwhite females 


1.03 


1.04 


1.09 


White males to White females 


77 


1 07 


1.05 


Nonwhite males to White males 


.84 


1.44 


1.80 


Nonwhite males to White females 


.65 


.68 


1.89 


Nonwhite females to White males 


.81 


1.39 


1.66 


Nonwhite females to White females 


.77 


1.48 


1.74 



Table 11 (continued) 



Facility utilization by diagnosis, 1975. 











Community 






f^pnpral 


pQ\/nhi?itrin 
r oy^i nail io 


Mpntal Hpalth 
ivid Hal rntJaiu I 






Hospital 


Services 


Centers 


Ratios 


Discharges 


Admissions 


Additions 


t. 


DGprossivQ Disord&rs 










Tntal Klnn\A/hitP tn tnt^il Whitp 

1 Ulal IMLn IVVI lilt. LU LUlCtl VVI NIC; 


4R 


1 1? 

1 . 1 c 


1 P.R 




Nonwhite males to Nonwhite females 


.32 


.13 


.43 




White males to White females 


.50 


.49 


.47 




Nonwhite males to White males 


o I 


.OH 


1 nn 




INUIIWiMltr IlldlCO LU Willie; ItslllCMGO 


1 fi 


.19 


47 

,H / 




Nonwhite females to White males 


.97 


2.92 


2.34 




Nonwhite females to White females 


.48 


1.42 


1.10 


r 
r 


ocnizopniGnia 










Tntal Klnn\A/hitp tn tnt^il Whitp 

1 f Idl INLJI IVVI IllC IU lUlul VVI lilt 


? 1 1 


1 Q1 

I . Z/ I 


? ?7 




Nonwhite males to Nonwhite females 


1.04 


.62 


1.21 




White males to White females 


.90 


1.06 


1.05 




Nonwhite males to White males 


AP. 


1 zin 


9 AA 




Mnn\A/hitp m:3lpQ tn \A/hitp tpm£*lpc 




1 4R 






Nonwhite females to White males 


2.19 


2.26 


2.02 




Nonwhite females to White females 


1.97 


2 40 


2.12 


r± 
Lj. 












Tntpl Mnn\A/hitp tn tnt^l Whitp 

1 vJldl INUI IVVI lilt IU ILHal VVI lilt; 


74 


ft? 


Klnt liQtprl 

INUl 1 1 OltU 




Nonwhite males to Nonwhite females 




.40 


Not listed 




White males to White females 


.72 


.48 


Not listed 




iNonwniie maies 10 wmie maies 




7 i 


INUt llblcU 




Klnn\A/hitP m^ilPQ tn Whitp fpmslpQ 

1 NUI 1 VV 1 II It? IlldlCo \.\J VVI IILC 1 tTI 1 1 aICo 




.35 


Klnt liQtpH 

1 N KJi 1 loLCU 




Nonwhite females to White males 


1.28 


1.78 


Not listed 




Nonwhite females to White females 


.93 


.86 


Not listed 


1 1 


Personality Disorders 










Tntnl Mnn\A/hitp tn tnt^il \A/hitp 
1 Uictl INUI IWl tlLC IU LUldl VVI lilt; 


fin 




Klnt lictprl 

1 N f I 1 1 OLCLi 




Nonwhite males to Nonwhite females 


1.69 


1.37 


Not listed 




White males to White females 


1.02 


1.09 


Not listed 




Nonwhite males to White males 


1 no 


.D I 


inoi Mbieu 




Nnnwhitp malps tn Whitp fpmalps 

1 KJ 1 IVVI MM | | 1 <_i 1 \_/ O l\J VVI IIL\_- 1^1 1 rCJ.IV'O 


77 


fi7 


Klnt liQtpH 

1 N \Jl 1 lolCLJ 




Nonwhite females to White males 


.45 


.45 


Not listed 




Nonwhite females to White females 


.46 


.49 


Not listed 


I. 


Transient Disorders 










Total Nonwhite to total White 


1 .02 


1 .21 


Not listed 




Nonwhite males to Nonwhite females 


.96 


.55 


Not listed 




White males to White females 


.71 


.80 


Not listed 




Nonwhite males to White males 


1.21 


.95 


Not listed 




Nonwhite males to White females 


.36 


.76 


Not listed 




Nonwhite females to White males 


1.26 


1.74 


Not listed 




Nonwhite females to White females 


.89 


1.39 


Not listed 



174 



Table 11 (continued) 



Facility utilization by diagnosis, 1975. 



Ratios 


Non-federal 
General 
Hospital 

Discharges 


Outpatient 
Psychiatric 
Services 
Admissions 


Community 
Mental Health 
Centers 
Additions 


J. Childhood Disorders 

Total Nonwhite to total White 
Nonwhite males to Nonwhite females 
White males to White females 


Insufficient 
data 


1.23 
1.81 
2.44 


1.36 
1.36 
1.24 


Nonwhite males to White males 
Nonwhite males to White females 
Nonwhite females to White males 
Nonwhite females to White females 


Insufficient 
data 


1.12 

2.73 
.62 
1.51 


1.42 
1.76 
1.04 
1.29 


K. Social Maladjustment 

Total Nonwhite to total White 
Nonwhite males to Nonwhite females 
White males to White females 




1.32 
.27 
.50 


1.36 
.80 
1.24 


Nonwhite males to White males 
Nonwhite males to White females 
Nonwhite females to White males 
Nonwhite females to White females 




.83 
.41 
3.05 
1.52 


.78 
.42 
1.04 
1.29 



Source: Compiled and abstracted by CHESS. Computed from various tabular data contained in National Institute of Mental Health, 
Series CN No. 2. Characteristics of Admissions to Selected Mental Health Facilities, 1975: An annotated book of charts and tables. 
DHHS Pub. No. (ADM) 81-1005, Superintendent of Documents, U.S. Government Printing Office, Washington, DC, 1981. Table 
5D, p. 59, Table 5E, p. 60, Table 4F, p. 54. 



Table 12 

Number of discharges and hospital days due to mental disorders, Indian Health Service and contract general hospitals, fiscal years 1967-72. 



Fiscal Year 




1982 


1976 


1972 


1971 


1970 


1969 


1968 


1967 


Total Number of Discharges 


4,954 


6,833 


6,017 


5,310 


4,750 


4,631 


3,922 


3,092 


IHS Hospitals 
Contract Hospitals 


3,956 
998 


4,948 
1,885 


4,662 
1,355 


4,138 
1,172 


3,657 
1,093 


3,665 
966 


3,003 
919 


2,430 
662 


Total Hospital Days 






40,521 


36,198 


26,571 


28,501 


27,737 


19,614 


IHS Hospitals 
Contract Hospitals 






34,666 
5,855 


29,343 
6,855 


22,189 
4,382 


24,630 
3,871 


22,462 
5,275 


16,507 
3,107 



Source: Indian Health Service. Indian Health Trends and Services. 1978 edition DHEW Pub. (HSA) 78-12009 Table 6 7 



Table 13 

Fifteen leading causes of outpatient visits by diagnostic classification. 1 Indian Health Service facilities, 



fiscal year 1976. 

Percent 

Diagnostic classification and ICDA code Number distribution 

Total, all causes 2,812,821 100 0 

Respiratory system (460-519) 432,607 15.4 

Accidents, poisonings, and violence (800-999) 192,218 6.8 

Skin diseases (580-709) 191,172 6.8 

Infective and parasitic diseases (001-136) 149,479 5.3 

Symptoms and ill-defined conditions (780-796) 149,090 5.3 

Ear diseases (380-389) 141,913 5.0 

Circulatory system (390-458) 124,099 4.4 

Endocrine, nutritional, and metabolic (240-279) 114,770 4.1 

Eye diseases (360-379) 111 ,844 4.0 

Pregnancy, childbirth, and puerperium (630-678) 106,770 3.8 

Musculoskeletal system (710-738) ... .' 97,149 3.5 ' 

Digestive system (520-577) 85,628 3.0 

Female genitalia and breast (610-629) 64,829 2.3 

Mental disorders (290-315) 57,244 2.0 

Diseases of urinary tract (580-599) 45,084 1.6 

Supplementary and all other diagnoses and no diagnosis code provided 748,925 26.6 



1 The number of problem or clinical impressions recorded are not the same as the number of outpatient visits Provisions are made 
on the Ambulatory Patient Care reporting form for recording the two most significant problems or clinical impressions observed 
during a visit 

Source: Indian Health Service Indian Health Trends and Services. 1978 edition DHEW Pub. (HSA) 78-12009. Table 6.4 



176 



Table 14 



Ten leading causes of hospitalization, Indian Health Service and contract hospitals, fiscal year 1976. 


Diagnostic category 




Number of discharges 




Percent distribution 


Total 


IHS 


Contract 


IUC 

I no 


ooniraci 


All diseases 


1 U4,4o0 


/ D, / I / 


OQ 71Q 


100.0 


100.0 


L/Ompiicdiionb oi prt^yridi icy, cr iiiuijirui, driu 












puGrpGnum 


1 Q /im 
1 o,4U 1 


1 o 7QQ 

I o, / Oo 


a fin 


18.2 


16.1 


AppiHontc nAicnni nnc onrl \/inlDnrD 


1 O, / \Dc. 


1 n R14 

I U,D I ^+ 


c; no 
O, I oo 


14.0 


17.9 


r^l ioqqcqc /™\f rcicnirotrir\/ c\ / ctom 


1 1 ORR 
I I ,UOO 


7 ^QR 


T APR 


10.0 


12.1 


UlSedbtJb OI UIQGbllvt? bybLtMll 


7 P.07 


O, I d. I 




6.8 


8.7 


Mpnt^l HicnrHprQ 


6,833 


4,948 


1 885 


6.5 


6.6 


Infective and parasitic diseases 


5,401 


4,325 


1,076 


5.7 


3.7 


Special conditions and examinations 


5,933 


5,405 


528 


7.1 


1.8 


Diseases of nervous system and sense 












organs 


4,903 


3,625 


1,278 


4.8 


4.5 


Diseases of genitourinary system 


4,941 


3,427 


1,514 


4.5 


5.3 


Diseases of circulatory system 


4,663 


3,203 


1,460 


4.2 


5.1 


All other diseases 


18,899 


13,666 


5,233 


18.0 


18.2 



Source: Indian Health Service. Indian Health Trends and Services. 1978 edition DHEW Pub (HSA) 78-12009. Table 6.7 

Table 15 

Alcoholism deaths and crude death rates, American Indians and Alaska Natives in 25 reservation States, and United States, all races (all States). 

1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 

Number of Deaths 

American Indians and 
Alaska Natives 



Alcoholism 55 51 91 81 97 107 102 159 164 171 NA NA NA NA 

Alcoholic psychoses 5 6 10 7 8 10 8 5 7 4 NA NA NA NA 

Cirrhosis of liver with 



mention of alcoholism 


128 


126 


165 


179 167 217 205 235 246 228 NA 


NA 


NA 


NA 


Total 


188 


188 


266 


267 272 334 315 399 417 403 425 


429 


437 


398 










Alcoholism Death Rates (Deaths per 100,000 Population) 








American Indians and 
















Alaska Natives 
















Alcoholism 


8.9 


8.0 


13.8 


11.9 13.8 14.8 13.6 20.7 20.8 20.5 NA 


NA 


NA 


NA 


Alcoholic psychoses 


0.8 


0.9 


1.5 


1.0 1.1 1.4 1.1 0.7 0.9 0.5 NA 


NA 


NA 


NA 


Cirrhosis of liver with 
















mention of alcoholism 


20.7 


19.7 


25.0 


26.3 23.8 30.1 27.4 30.5 31.1 27.3 NA 


NA 


NA 


NA 


Total 


30.4 


28.6 


40.3 


39.2 38.7 46.3 42.1 51.9 52.8 48.3 48.3 


47.9 


44.8 


NA 










Alcoholism Death Rates (Deaths per 100,000 Population) 








U.S. All Races 
















Alcoholism 


1.6 


1.5 


2.0 


2.0 2.1 2.1 2.1 2.2 2.3 NA NA 


NA 


NA 


NA 


Alcoholic psychoses 


0.3 


0.3 


0.3 


0.3 0.3 0.3 0.2 0.2 0.2 NA NA 


NA 


NA 


NA 


Cirrhosis of liver with 
















mention of alcoholism 


4.8 


4.8 


5.0 


5.2 5.5 5.8 6.0 6.0 6.2 NA NA 


NA 


NA 


NA 



Total 6.7 6.6 7.3 7.5 7.9 8.2 8.3 8.4 8.7 8.6 8.6 8.5 8.5 NA 



Source: Indian Health Service. Indian Health Trends and Services. 1978 edition DHEW Pub. (HSA) 78-12009. Table 4.14 



177 



Table 16 

Distribution by mental disorder of utilization of Indian Health Service Hospitals (including contract 
hospitalizations), fiscal years 1967-72. 



Nature of Mental Disorder 



Fiscal Year 



1972 



1971 



1970 



1969 



1968 



1967 



Total 100.0 
Alcoholism and Drug 
Dependence 1 
Neuroses and Personality 
Disorders 

Psychoses (Non-organic) 
Transient Situational 
Organic Brain Syndrome 2 
All Others 



100.0 



Percent Distribution 
100.0 100.0 



100.0 



100.0 



67.7 

16.9 
5.9 
2.8 
2.4 
4.3 



Total 1.5 
Alcoholism and Drug 

Dependence 1 2.9 
Neuroses and Personality 

Disorders 0.3 

Psychoses (Non-organic) 0.7 

Transient Situational 0.3 

Organic Brain Syndrome 2 2.3 

All Others 0.6 



64.6 

19.4 
6.2 
3.0 
2.7 
4.1 



1.4 



65.0 

19.3 
5.5 
2.4 
3.0 
4.8 



64.5 

20.3 
4.9 
2.8 
3.2 
4.3 



Male to female sex ratio 
1.3 1.3 



59.1 

23.0 
4.9 
2.7 
3.6 
6.7 



1.2 



55.7 

25.6 
6.5 
2.9 
3.6 
5.7 



1.2 



2.5 

0.4 
0.8 
0.3 
1.4 
0.6 



2.3 

0.3 
0.6 
0.3 
1.3 
0.7 



2.5 

0.3 
0.5 
0.3 
1.4 
0.7 



2.4 

0.3 
0.9 
0.3 
2.4 
0.6 



2.6 

0.3 
0.7 
0.4 
1.2 
0.5 



1 1ncl. alcohol psychosis. 
2 Excl alcohol psychosis. 

Table 17 

Suicide deaths and age-adjusted rates per 100,000 population for Indians and Alaska Natives in reser- 
vation States and for United States, all races, 1959 to 1975. 



Number 



Age-adjusted rates and their ratio 



Year 


Indians and 
Alaska Natives 


U.S. 
All Races 


Indians and 
Alaska Natives 


U.S. 
All Races 


Ratio of 
Indians to 
U.S. All Races 


1979 


188 


NA 


21.8 


11.9 


1.8 


1978 . . 


150 


27,294 


18.5 


12.0 


1.5 


1977 


199 


28,681 


26.6 


12.9 


2.1 


1976 


168 


26,832 


22.5 


12.3 


1.8 


1975 . . 


180 


27,063 


26.0 


12.6 


2.1 


1974 . . 


148 


25,683 


21.8 


12.2 


1.8 


1973 


149 


25,118 


22.9 


12.0 


1.9 


1972 


133 


25,004 


20.6 


12.1 


1.7 


1971 . . 


135 


24,092 


21.8 


11.9 


1.8 


1970 . . 


105 


22,630 


17.9 


11.8 


1.5 


1 969 


94 


22,364 


16.8 


11.3 


1.5 


1968 . 


90 


21,372 


17.5 


11.0 


1.6 


1967 


94 


21,325 


16.2 


11.1 


1.5 


1966 


64 


21,281 


15.2 


11.2 


1.4 


1965 


65 


21,507 


12.9 


11.4 


1.1 


1964 


52 


20,588 


15.8 


11.0 


1.4 


1963 


66 


20,825 


15.6 


11.3 


1.4 


1962 . . 


59 


20,207 


16.9 


11.1 


1.5 


1961 


61 


18,999 


16.7 


10.5 


1.6 


1960 


57 


19,041 


16.8 


10.6 


1.6 


1959 


57 


18,633 


17.0 


10.6 


1.6 



Source: 1 
2) Indian 



) Indian Health Service. Indian Health Trends and Services. 1978 edition DHEW Pub. (HSA) 78-12009. Table 4.11. 
Health Service. FY 1984 Budget Appropriation Chart Series Tables. April 1983. 



178 



Table 18 

Homicide deaths and age-adjusted rates per 100,000 population for Indians and Alaska Natives in 
reservation States and for United States, all races, 1959 to 1975. 

Number Age-adjusted rates and their ratio 

Ratio of 





Indians and 


U.S. 


Indians and 


U.S. 


Indians to 


Year 


Alaska Natives 


All Races 


Alaska Natives 


All Races 


U.S. All Races 


1975 . . 


185 


21,310 


26.5 


1 0 5 


2.5 


1974 


203 


21,465 


30.1 


10.8 


2.8 


1973 


196 


20,465 


29.6 


10.5 


2.8 


1972 . . 


153 


19,638 


27.6 


10.3 


2.7 


1971 . . 


149 


18,787 


26.1 


10.0 


2.6 


1970 . . 


125 


16,848 


23.8 


9.1 


2.6 


1969 . . 


1 61 


1 5,4/ / 


22. b 


8.6 


2.b 




1 1fi 


1 4,686 


22.2 


8.2 


2.7 


1 Qfi7 


1 10 


1 3,425 


20.3 


7.7 


2.6 




79 


1 1 ,606 


20.3 


6.7 


"3 0 


1965 . . 


102 


10,712 


19.7 


6.3 


3.1 


1964 , . 


84 


9,814 


23.6 


5.8 


4.1 


1963 


85 


9,225 


22.3 


5.5 


4.1 


1962 


80 


9,013 


21.0 


5.5 


3.8 


1961 


63 


8,578 


20.9 


5.3 


3.9 


1960 . . 


80 


8,464 


19.5 


5.3 


3.7 


1959 . . 


62 


8,159 


20.5 


5.1 


4.0 


1976 . . 


185 


19,554 


26.6 


9.5 


2.8 


1977 . . 


197 


19,968 


26.5 


9.6 


2.8 


1978 . . 


218 


20,432 


27.8 


9.6 


2.9 


1978 


209 


22,550 


25.5 


10.4 


2.5 



Source: Indian Health Service. Indian Health Trends and Services. 1978 edition DHEW Pub (HSA) 78 12009 Table 4.13. 



Table 19 

Race breakdown by quarter (in percentages) in use of drug clinics. 



1975 1976 





1st 


2nd 


3rd 


4th 


1st 


2nd 


Race 


Quarter 


Quarter 


Quarter 


Quarter 


Quarter 


Quarter 


White 


53.4 


52.6 


51.6 


52.1 


51.8 


50.7 


Black 


34.8 


35.2 


36.1 


35.4 


35.1 


36.2 


Spanish American 


10.4 


10.8 


10.8 


11.0 


11.7 


11.8 


Other 


1.4 


1.4 


1.5 


1.5 


1.4 


1.3 


Total 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


Total N 


51,762 


50,842 


53,389 


35,844 


59,171 


55,045 



Source: National Institute on Drug Abuse, U S DHEW. Dafa from the Client Oriented Data Acquisition Process (CODAP), Statistical 
Series Quarterly Report, April-June 1976. 



179 



Table 20 

Race breakdown by quarter for clients abusing barbiturates, amphetamines, opiates, and marijuana (in percentages). 



Clients abusing barbiturates (in percentages). 






1975 








1976 




1 ct 
I bl 


c. \ IU 




or U 


4th 


1 ct 
I SI 




^no 


Race Quarter 


Quarter 




Quarter 


Quarter 


Quarter 




Quarter 


White 82.5 


79.8 




78.4 


79.4 


78.8 




77.4 


Black 11.5 


13.9 




14.5 


13.5 


12.2 




13.3 


Spanish American 4.5 


5.1 




4.6 


4.8 


6.6 




6.6 


Uther l.o 


1 .2 




2.5 


2.3 


2.5 




2.7 


Total 1 0f) 0 


100.0 




100.0 


1 00.0 


1 00.0 




1 00 0 

I uu . u 


Total N 2 494 


2,447 




2,367 


2,860 


2,741 




9 575 


unenis auusing ampneiamines (jn percenidgebj 




















1975 








1976 




1 ct 
I bl 


9nH 




ftrH 
Ol U 


4th 


1 ct 
I bl 






Race Quarter 


Quarter 




Quarter 


Quarter 


Quarter 




Quarter 


White 87.3 


86.1 




85 2 


82.6 


85.0 




84.0 


Black 8.3 


9.7 




10.6 


11.3 


10.7 




11.7 


Spanish American 2.6 


2.8 




2.3 


4.3 


3.2 




3.1 


Other 1 .8 


1 .4 




1 .4 


1 .8 


1 .1 




1 .3 


Total 1 00 0 
I uidi I uu.u 


1 oo n 

UU.U 




1 on o 


1 00 0 


1 00 0 




1 00 0 

I UU.U 


Total M 9 ^56 

I UlCll IN £.,,_>UU 


9 90^ 




9 14? 


9 519 

L,U 1 u 






9 555 

L,UUU 


unenis auusing opiates (in percenidgesj. 




















1975 








1976 




1 ct 
I SI 


^no 




oro 


4th 


1 ct 
I bl 






Race Quarter 


Quarter 




Quarti - 


Quarter 


Quarter 




Quarter 


White 38.3 


38.0 




38.3 


38.9 


38.7 




38.6 


Black 47.5 


47.5 




47.6 


46.2 


45.8 




46.0 


Spanish American 13.4 


13.8 




13.1 


13.8 


14.4 




14.4 


Other 0.9 


0.9 




1 .0 


1 .0 


1 .1 




1 .0 


Tntal 1 OO 0 
I (JLdl I UU.U 


1 00 0 




1 00 0 


1 00 0 

I UU.U 


1 00 0 

I UU.U 




1 00 0 

I UU.U 


Tntal M 9ft 1 7^ 
I Uldl In ^-O, I / O 


9R 79S 




"31 4ft1 


ft4 9fi'3 


4SQ 




OC CO/ 
OU.UOH 


Clients abusing marijuana (in percentages). 




















1975 








1976 




1st 


2nd 




3rd 


4th 


1st 




2nd 


Race Quarter 


Quarter 




Quart. T 


Quarter 


Quarter 




Quarter 


White 70.0 


68.8 




67.0 


68.5 


69.9 




69.6 


Black 19.2 


20.4 




20.9 


20.1 


18.5 




19.6 


Spanish American 8.4 


8.2 




9.6 


8.6 


9.8 




8.9 


Other 2.4 


2.5 




2.5 


2.8 


1.8 




1.9 


Total 100.0 


100.0 




100.0 


100.0 


100.0 




100.0 


Total N 8,339 


7,816 




7,570 


6,958 


6,314 




4,902 



Source: National Institute on Drug Abuse, U S DHEW. Data from the Client Oriented Data Acquisition Process (CODAP). Statistical 
Series Quarterly Report, April-June 1976 



180 



References 

1 . Eaton, W., Regier, D., 
Locke, B., and Taube, C: 
"The Epidemiologic Catch- 
ment Area Program of the 
National Institute of Mental 
Health." Public Health 
Reports. Vol. 96, No. 4. July- 
August 1981. 

2. Robins, L, Helzer, J., 
Croughan, J., and Ratchiff, 
K.: "National Institute of Men- 
tal Health Diagnostic Inter- 
view Schedule: Its History, 
Characteristics, and Validity." 
Arch. Gen. Psychiatry. Vol. 
38. April 1981. 

3. Cannon, M.S., and Locke, 

B. Z.: "Being Black Is 
Detrimental to One's Mental 
Health: Myth or Reality?" 
Paper presented at W.E.B. 
Duboise Conference, the 
Health of Black Populations. 
Atlanta, GA, December 14, 
1976. 

4. Rosen, B.M.: "Mental 
Health and the Poor: Have 
the Gaps Between the Poor 
and the 'Nonpoor' Narrowed 
in the Last Decade?" Paper 
presented at the Conference 
on Social Sciences in Health 
at the 102nd Annual Meeting 
of the American Public 
Health Association, October 
21, 1974. 

5. Institute of Medicine of the 
National Academy of 
Sciences: Behavior, Health 
Risks, and Social Disadvan- 
tage. In Parron, D., Solomon, 
F., Jenkins, C. (eds.) National 
Academy Press, Washington, 
DC, 1982. 

6. Strauss, J.: "Behavioral 
Aspects of Being Disadvan- 
taged and Risk for 
Schizophrenia." In Institute of 
Medicine of the National 
Academy of Sciences. 
Behavior, Health Risks, and 
Social Disadvantage. Parron, 
D., Solomon, F., and Jenkins, 

C. (eds.) National Academy 
Press, Washington, DC, 
1982. 



7. Brenner, M.: "Mental Ill- 
ness and the Economy." In 
Institute of Medicine of the 
National Academy of 
Sciences. Behavior, Health 
Risks, and Social Disadvan- 
tage. Parron, D., Solomon, 
F., and Jenkins, C. (eds.) Na- 
tional Academy Press, 
Washington, DC, 1982. 

8. Kramer, M.: "Population 
Changes and 
Schizophrenia." In Wynne, 
L, Cromwell, R., Matthyse, 
T.S. (eds.) The Nature of 
Schizophrenia. John Wiley & 
Sons, New York, 1978. 

9. Williams, D.: "American 
Racism and the Study and 
Treatment of Severe Mental 
Illness in Afro-Americans." In 
Institute of Medicine of the 
National Academy of 
Sciences. Behavior, Health 
Risks, and Social Disadvan- 
tage. Parron, D., Solomon, 
F., and Jenkins, C. (eds.) Na- 
tional Academy Press, 
Washington, DC, 1982. 

10. American Public Health 
Association: "Decreases in 
Teens' Drug Use Shown to 
Continue in 1983." The Na- 
tion's Health. Washington, 
DC, March 1984. 



List of Tables 

1 . Mental health services by 
service mode 1970-1980. 

2. Number of inpatient addi- 
tions, outpatient additions, 
and day treatment additions 
by type of mental health 
facility: United States, 
selected years 1969-79. 

3. Number of resident pa- 
tients, total admissions, net 
releases, and deaths, State 
and county mental hospitals: 
United States, 1950-1980. 

4. Distribution of additions to 
federally funded community 
mental health centers by age, 
sex, and race. United States, 
1978. 

5. Utilization of mental health 
facilities, 1975. 

6. Hispanic American admis- 
sions as a percent of total 
admissions by type of facility: 
selected mental health 
facilities, United States, 1975. 

7. Age-adjusted admission 
rates per 100,000 population 
by race/ethnicity and sex: 
selected mental health 
facilities, United States, 1975. 

8. Median age of admissions 
by sex and race/ethnicity: 
selected mental health 
facilities, United States, 1975. 

9. Median years of education 
of admissions to selected 
mental health facilities com- 
pared with median years of 
education of the general 
United States population by 
race/ethnicity. United States, 
1975. 

10. Diagnostic category 
utilization by facility type, 
1975. 

1 1 . Facility utilization by 
diagnosis, 1975. 

12. Number of discharges 
and hospital days due to 
mental disorders, Indian 
Health Service and contract 
general hospitals, fiscal years 
1967-1972. 

13. Fifteen leading causes of 
outpatient visits by diagnostic 
classification, Indian Health 



Service facilities, fiscal year 
1976. 

14. Ten leading causes of 
hospitalization, Indian Health 
Service and contract 
hospitals, fiscal year 1976. 

15. Alcoholism deaths and 
crude death rates, American 
Indians and Alaska Natives in 
25 reservation States, and 
United States, all races, (all 
States). 

16. Distribution by mental 
disorder of utilization of In- 
dian Health Service Hospitals 
(including contract 
hospitalizations), fiscal years 
1967-1972. 

17. Suicide deaths and age- 
adjusted rates per 100,000 
population for Indians and 
Alaska Natives in reservation 
States and for United States, 
all races, 1959 to 1975. 

18. Homicide deaths and 
age-adjusted rates per 
100,000 population for In- 
dians and Alaska Natives in 
reservation States and for 
United States, all races, 1959 
to 1975. 

19. Race breakdown by 
quarter (in percentages) in 
use of drug clinics. 

20. Race breakdown by 
quarter for clients abusing 
barbiturates, amphetamines, 
opiates, and marijuana (in 
percentages). 

List of Figures 

1. Graphic analysis of the 
relation between the changes 
in the suicide rate and 
changes in the unemploy- 
ment rate, United States, 
1905-1976. 

2. Utilization of federally 
funded drug abuse clinics. 



181 



Chapter VIII 



Dental Health 



Table of Contents 

Overview 185 

A. Introduction 185 

B. Dental Care Services Utilization 185 

C. Decayed, Missing, and Filled Teeth 188 

D. Periodontal Disease 189 

E. Edentulism 189 

F. Oral Hygiene 190 
Tables 191 
References 203 

List of Tables 203 
List of Figures 204 



183 



184 



Chapter VIII 



Dental Health 



Overview 

Four measures of dental 
health status were utilized to 
analyze the various 
demographic variables of in- 
terests: (a) utilization of dental 
health services; (b) dental 
caries; (c) periodontal 
disease; and (d) missing 
teeth. All four of these 
measures indicated poor 
dental health among those of 
lower income, those of lower 
formal educational levels, and 
those residing in rural areas. 
These measures varied in 
their indication of whether 
racial minorities had poorer 
or better dental health status. 
All four measures also in- 
dicated that any disparities 
that exist are lessening or 
have lessened over time. 

Many studies have been 
conducted on dental health 
services utilization since 
1930. In the last 50-year 
period, the rate of persons 
having at least one dental 
visit during the preceding 
year rose from approximately 
25 percent to approximately 
50 percent. All of the studies 
that included such demo- 
graphic variables showed 
that utilization rates were 
substantially higher among 
whites, women, those with 
higher income, the more 
highly educated, those living 
in the more densely 
populated areas, and those 
in the Northeast and Far 
West. 

Utilization rates of blacks 
have changed rapidly in the 
last two decades. Twenty 
years ago, white utilization 
rates were almost twice the 
nonwhite races. The gap had 
narrowed to 1.64 times the 
nonwhite rate by 1981. If that 



rate of increased use con- 
tinues, the gap will be 
eliminated by the turn of the 
century. 

Hispanics formed two 
groups with respect to utiliza- 
tion. One group was com- 
prised of Mexican-Americans, 
whose utilization rates were 
similar to those of blacks. 
The other was comprised of 
all other Hispanics; their 
utilization rates were approx- 
imately midway between the 
rates of blacks and those of 
whites for visits during the 
last year, and about the 
same or slightly higher than 
whites for the number of an- 
nual visits. 

The Public Health Service 
Health Examination Survey 
used actual dentists' ex- 
aminations of teeth, rather 
than self reports, as data. 
This fact should have made 
the data more accurate than 
other extant health status 
data. But the dentists had 
constraints on their proce- 
dures disallowing the use of 
dental xrays or other than 
superficial examination of 
teeth. We can assume that 
their observations of fillings 
and missing teeth are very 
accurate. Their measure- 
ments of dental caries, on the 
other hand, may have 
resulted in lower rates than 
might have been reported if 
radiographs had been used. 
But there is no reason to 
believe that any examination 
errors should not have been 
random with respect to 
racial/ethnic and other 
demographic variables. Given 
this caveat, the data clearly 
show that as family income 
and educational levels in- 
crease, the mean number of 
decayed teeth decreases, the 
number of filled teeth in- 
creases, and the number of 
missing teeth decreases. As 
for race, blacks have higher 



decay rates (particularly 
among women), slightly 
higher missing teeth rates, 
and substantially lower filled 
teeth rates. Caution is sug- 
gested in interpreting the 
composite DMF (decayed, 
missing, and filled teeth) rates 
reported, since almost all of 
the composite score differ- 
ences are attributable to filled 
teeth. 

The incidence of periodon- 
tal disease was much higher 
among males than among 
females. Black females had 
consistently higher periodon- 
tal disease rates than did 
white females at all income 
and education levels; black 
males had the highest rates 
of all racial/sexual groups. 

Judgments by examining 
dentists as to the need for 
dental care, and thus the oral 
health status, of the U.S. 
population varied inversely 
with income and educational 
levels of patients. Blacks 
were judged to require dental 
care at rates about 67 per- 
cent above whites. 
A. Introduction 
An exact gauge of the dental 
health status of a nation or of 
a subpopulation within a na- 
tion is difficult to obtain. A 
comparative statement is dif- 
ficult to make, because com- 
parable data are not 
available from other coun- 
tries. An absolute statement 
is likewise difficult, because 
there is no way of knowing 
what the dental health of our 
Nation should be. This 
becomes more apparent 
when we look at the 
measures that are available 
for assessing dental health 
status. 

The major dental prob- 
lems are diseased teeth, 
diseased tissues surrounding 
the teeth (periodontal 



disease), or missing teeth 
(edentulism). When the teeth 
themselves are diseased, by 
far the major contributing fac- 
tor is dental caries (cavities). 
The effect of dental caries 
can be measured as an un- 
treated cavity or as a filling, 
the difference being that in 
the latter case an arrest of 
the disease process has 
taken place, and a health 
care need has been met. 

As indicated previously, it 
is difficult to arrive at an ab- 
solute standard for dental 
health, since the total 
absence of these problems is 
an unrealistic standard and 
there are no criteria by which 
the minimal rates for these 
problems can be specified. 
Our analyses of dental health 
status are therefore limited to 
enumerations of dental health 
services utilization and the 
presence of caries, periodon- 
tal disease, and missing 
teeth; to shifts in these 
measures over time; and to 
comparisons of the these in- 
dexes between subpopula- 
tions. These analytic ap- 
proaches are detailed in the 
rest of this chapter. 

Additional caveats on the 
interpretation of the data 
presented are contained in 
Chapter I of this book. 
B. Dental Care Services 

Utilization 
In the previous edition of this 
book, a careful 50-year 
analysis was made of the 
patterns of the dental serv- 
ices utilization. The documen- 
tation of all the various 
studies leading to the 
analysis will not be repeated 
here, although we must ex- 



185 



amine those findings before 
continuing our look at the 
dental health status of 
minorities and low income 
groups (1-10). Table 1 sum- 
marizes the 50 years of 
study, showing the patterns 
of dental service utilization 
within that period of time. 

Usually dental service 
utilization is measured in one 
of three ways: (a) whether or 
not a respondent (and/or 
family members) had visited 
a dentist within the past 1 or 
2 years; (b) how many dental 
visits were made for respon- 
dent (and/or family members) 
within some period of time; 
or (c) the period of elapsed 
time since the last dental 
visit. Table 1 reports studies 
that used the first of these 
measures and shows a very 
definite pattern: Since the 
1930's, there has been an in- 
creased use of dental serv- 
ices by the American popula- 
tion. The rate has increased 
from 2.0 to 2.5 times the in- 
itial rate recorded at the 
beginning of that time period 
and is probably still on the 
increase. 

We might posit reasons 
for such a change by inver- 
ting the problem. That is, we 
could hypothesize the 
reasons why people may not 
seek dental care and deter- 
mine whether or not there is 
any evidence to support any 
of those hypotheses. These 
hypotheses would include: 

1 . Dental care is not 
needed. 

2. Dental care is per- 
ceived as an unneeded 
service. 

3. Dental care is 
unaffordable. 
Probably no factors have 

caused an individual's need 
for dental services to rise; in- 
deed, fluoridated toothpastes 
and water supplies might 
have induced the reverse ef- 
fect. Thus we can probably 



eliminate the first reason. 
There have not been any 
drastic changes in overall af- 
fluence within the more re- 
cent years of this period, at 
least none that would pro- 
duce the magnitude of the 
changes noted. This probably 
eliminates the third reason. 
This leaves changes in needs 
perception, which probably 
has contributed most heavily 
to the trend noted. Let us ex- 
plore this reason further. 

It has been suggested 
that, psychologically, in- 
dividuals may perceive the 
need for dental care with 
much less of a sense of 
urgency than other health 
problems, for the following 
reasons: 

1. In early stages, dental 
caries and most periodon- 
tal disorders are not 
detectable. 

2. Dental diseases do not 
usually lead to gross 
disability until fairly 
advanced stages (i.e., 
people can still masticate, 
and if there is some pain, 
they can tolerate it). 

3. Most adults have 28 to 
32 teeth to lose before 
becoming totally eden- 
tulous, while they only 
have two arms, two eyes, 
etc. Therefore they can af- 
ford to lose a tooth or two 
and still be quite functional 
as far as mastication is 
concerned. 

4. If teeth are lost, they 
can be replaced at a price 
within reach. 

In other words, people 
may have believed that they 
could afford to be more 
casual about their dental 
health than they could about 
other body systems and suf- 
fer fewer untoward effects, in- 
cluding debility. As we shall 
see, educational levels of the 
head of household have a 
powerful effect on dental 
services utilization, so if we 
accept a correlation between 
educational level and the 



understanding of the need 
for dental care, perhaps we 
can also accept that the 
perception of need for dental 
care is the most potent factor 
determining dental services 
usage. 

Table 2 presents data on 
the intervals since the last 
dental visit, taken from the 
National Health Interview 
Survey. Although the 17-year 
period charted in that table 
(1964 to 1981) has witnessed 
a decrease in those who 
have never visited a dentist, 
that rate seems to have 
stabilized at just under 1 1 
percent. The breakdown of 
these respondents demon- 
strates that most of those 
who are in this category are 
the young, who apparently 
do not visit the dentist with 
any frequency before they 
get their permanent teeth. 
From the breakdown by fami- 
ly income, it appears that 
there was a relatively strong 
economic basis to this health 
behavior in 1964. But that ef- 
fect lessened by 1976, and 
lessened even further by 
1981 , at which time the 
economic factor was a less 
profound factor than age. 
Thus, one reason why dental 
utilization rates are not higher 
may be that we have almost 
reached a point where the 
need for dental services for 
young children has been 
met. 

When those data are 
analyzed by race, we note 
that, with respect to numbers 
of visits, there have been 
practically no changes in the 
practices of whites, but there 
does seem to have been a 
change among blacks. The 
white-to-black ratio with 
respect to dental visits was 
1.89 in both 1964 and 1975, 
but by 1981 this ratio had 
dropped to 1.64. If this rate 
of change were to continue, 
the ratio would drop to 1 .0 
by the end of the century. 



A similar change is ap- 
parent regarding the interval 
since the last visit. In 1946 to 
1981 , the proportion of 
whites who had seen a den- 
tist within the preceding 1 1 
months increased by 7.5 per- 
cent, while the proportion of 
blacks who had seen a den- 
tist within the preceding 1 1 
months increased by 12.7 
percent. The ratio of differen- 
tials was 1.96 in 1964, 1.57 
in 1976, and 1.47 in 1981. 
Again, if this rate of change 
were to continue, the dif- 
ferential would hit parity by 
the turn of the century. 

A similar pattern occurs 
for those who have never 
visited a dentist. During 1946 
to 1981, the proportion of 
whites never having visited a 
dentist dropped 3.3 percent, 
while the black proportion 
dropped 12.8 percent, with 
the differential ratio decreas- 
ing from 1.96 to 1.62 to 1.40. 
If this rate of change were to 
continue, this disparity would 
also disappear by the turn of 
the century (see Table 2). 

In analyzing the three 
measures (never visited, 
number of visits, and interval 
since last visit) as a function 
of the five income groups 
listed in Table 2, we notice 
that the upper two income 
groups have been relatively 
static (actually, with respect 
to number of visits, there has 
been a decrease). We also 
note that the lower three in- 
come groups (particularly the 
lowest two income groups) 
have had substantially in- 
creased dental services 
utilization (see Table 2). 

A similar picture emerges 
with respect to dental serv- 
ices utilization as a function 
of population density. The 
changes that have occurred 
over time have been greater 
outside of Standard 
Metropolitan Statistical Areas 
than within, to the point 
where the differentials be- 
tween these geographic den- 
sities are becoming slight. 



186 



Figure 1A 

Unadjusted and age-adjusted percent of population with a dental visit 
within a year of interview, by family income: United States, 1978 and 1979 

Unadjusted 

Age-adjusted Percent of population with dental visit in past year 



Figure 1 B 

Unadjusted and age-adjusted percent of population with a dental visit 
within a year of interview, by education of head of family: United States, 
1978 and 1979 



0 



10 


20 


30 


40 


50 


60 


































































Hi 



























































































































































































































Less than 
$3,000 



$3,000- 
$4,999 



$5,000- 
$6,999 



$7,000- 
$9,999 



$10,000- 
$14,999 



$15,000- 
$24,999 



$25,000 
or more 



Source: National Center for Health Statistics: Dental Visits Volume and Interval Since 
Last Visit: United States, 1978 and 1979. DHHS Pub. No. (PHS) 82-1566. Series 10, Data 
from the National Health Survey; No. 138. Hyattsville, MD, April, 1982. 



70 



Although not shown in Table 
2, there has been a greater 
decrease in "never visited a 
dentist" rates among farm 
than among nonfarm 
residents within the category 
"outside SMSA." In fact, 
there has been an inversion. 
The nonf arm-to-farm ratio in 
1963-1964 was 1.13, drop- 
ping to 1.03 in 1969 and 
then inverting to 0.93 in 
1978-1979. 

With respect to the educa- 
tional level of the head of 
family, we see a profound 
correlational factor, but it is 
changing quite slowly. The 
differential ratio of dental 
visits within a year between 
those with family heads of 13 



and more years of education 
and those with less than 9 
years of education was 2.33 
in 1963-1964, 2.24 in 1969, 
and 2.17 in 1978-1979. In 
1978-1979, among those liv- 
ing in families whose head of 
household had 16 or more 
years of education, 69.1 per- 
cent had visited a dentist 
within the previous year. 

Figure 1 presents a com- 
parison between the effects 
of income and the effects of 
education of the head of 
family (to the extent that they 
can be compared). It ap- 
pears from the kurtosis of the 
distribution (i.e., the 
steepness of the curve) that 
the educational variable is 
the stronger of the two in 
determining utilization of den- 



Unadjusted 
Age-adjusted 

0 



Percent of population with dental visit in past year 



10 


20 


30 


40 


50 


60 


70 






















































































































































































— 1 

BnnHn 















Less than 
9 years 



9-11 
years 



12 

years 



13-16 
years 



18 years 
or older 



Source: National Center for Health Statistics: Dental Visits Volume and Interval Since 
Last Visit: United States, 1978 and 1 979. DHHS Pub. No. (PHS) 82-1 566. Series 1 0. Data 
from the National Health Survey; No. 138. Hyattsville, MD, April, 1982. 



tal services. This comparison 
does not appear to be a 
result of the parameters used 
to set up the income' and 
educational level groupings 
(11). 

Data on dental visits made 
by Hispanics in the 
1976-1978 time period can 
be found in Table 3 (12). 
These data are disag- 
gregated by four types of 
Hispanic origin. The fourth 
category, "other Spanish 
ancestry," is composed of 
persons of European (i.e, 
Spain) and South American 
origins. 

The overall proportion of 
Hispanics with dental visits is 
somewhat similar to the ratio 
for blacks. By disaggregating 
the data in this fashion, 
however, we find that there 
are two separate clusters of 
Hispanics. One cluster is 
made up of Mexican- 
Americans (the M-A Group) 



and the other of all other 
Hispanic groups (the A-0 
Group). 

The data for the M-A 
Group is somewhat similar 
(actually, it has slightly lower 
percentages) to that for 
blacks, while the data for the 
A-0 Group is approximately 
halfway between the data for 
blacks and the data for 
whites. Since Mexican- 
Americans constituted 57.3 
percent of all Hispanics dur- 
ing those years, they greatly 
affected the overall data. That 
effect is particularly evident 
from the ratios in parentheses 
behind each percentage en- 
try. For all ages, the M-A 
Group with incomes below 
$10,000 ran 32 percent 
behind all Hispanics in the 
same income bracket, and 
for those earning over 
$100,000 the disparity was 
12 percent. The differences 
between the three other 



187 



Hispanic groups are not suffi- 
ciently great to deserve addi- 
tional comment. 

The effects of income on 
dental services utilization also 
varied among the Hispanic 
subgroups, but this variable 
had a differential effect on 
the subgroups. The ratio of 
high income to low income 
group for persons with recent 
dental visits was 1 .45; for the 
"other Spanish ancestry" 
subgroup the ratio was 1.31; 
and for the Cuban subgroup 
that ratio was 1 .26. The in- 
come factor had an almost 
negligible effect on the 
Puerto Rican subgroup, for 
which the ratio was only 
1.09. Obviously, before an in- 
terpretation of these ratios 
can be made, the distribu- 
tions of income above 
$10,000 in those years and 
within those subgroups 
should be studied to deter- 
mine if the distributions are 
sufficiently similar between 
subgroups to allow conclu- 
sions to be drawn concerning 
these differential ratios (12). 

In 1976, the number of 
dental visits per person per 
year was 1.7 for whites and 
0.9 for blacks. Hispanics 
again were divided into two 
groups. Mexican-Americans 
constituted one group, with 
an average number of visits 
identical to blacks (0.9), while 
the other three Hispanic 
subgroups had visit rates 
equal to or slightly higher 
than that of whites (1.7 to 
1 .9). The pattern of visits by 
age group was distinct for 
each Hispanic subgroup. 
One noticeable difference 
was the very low rate of visits 
for those 65 and over among 
Mexican-Americans and 
Cubans, while the same age 
group had an unusually high 
visit rate among Puerto 
Ricans. These kinds of varia- 
tions are more typically 
generated by health care 



beliefs than by need for den- 
tal health care (see Table 4). 
Since those over 65 con- 
stitute a relatively small pro- 
portion of the Hispanic 
population, the validity of 
age-related factors must 
receive additional scrutiny. 

The effect of income on 
the number of dental visits 
was similar to its effect on 
dental visits within the 
previous year. The ratio of 
dental visits per person for 
the high income group to 
those for the low income 
group was 2.0 for Mexican- 
Americans, 2.61 for other 
Hispanics, and 1 .21 for 
Cubans. While the effect of 
income was negligible on re- 
cent visits for Puerto Ricans, 
that was not the case for 
numbers of visits by Puerto 
Ricans, since the ratio for 
these income classes within 
this ethnic subgroup was 
1 .43 (see Table 4). 

Table 5 illustrates some of 
the changes that have oc- 
curred in dental services 
utilization as a function of in- 
come. In this table, instead of 
a fixed income dividing the 
groups, the poverty levels for 
the respective years of the 
study are used. These 
poverty levels are listed at 
the bottom of the table. This 
table probably represents the 
best picture of how the 
changes in the acceptance of 
dental services as a 
necessary component of 
health care have occurred 
over time (13). 

For whites, over the 
17-year period traced by 
Table 5, there has been a 
decrease of about 12 percent 
in the proportion of the 
population with no dental 
visits in the past 2 years. The 
drop among the nonpoor in 
the same time period was 
approximately 7 percent. 
Among the poor, the age 
bracket that most seemed to 
reflect that same trend was 
persons under 17 years of 



age. The 45-64 age bracket 
demonstrated a similar trend, 
while the elderly age bracket 
(65 years and over) showed 
twice as large a decrease in 
persons with no dental visits. 

Among nonwhites, the ef- 
fects have been much more 
dramatic. The poor in this 
racial aggregation have seen 
a drop of 21.6 percent in the 
proportion of people who 
have not had a dental visit 
within the past 2 years, while 
the nonpoor have seen a 
drop of almost 16 percent. 
Among the poor, the biggest 
drop was again in the lowest 
age bracket (under 17). but 
significant decreases oc- 
curred in all age brackets. 
Among the nonpoor, the 
largest drop also occurred in 
the youngest age bracket, 
although a sizeable decrease 
occurred in the 45-64 age 
bracket as well. Some of 
these changes may have 
resulted from certain of the 
"Great Society" programs in- 
itiated in the 1960's. There is 
some question as to whether 
those programs (a) were suffi- 
cient in scope to bring about 
changes of this magnitude, 
(b) would have resulted in 
the continuing decline 'we 
have experienced, or (c) 
would have affected the non- 
poor. Perhaps we can posit 
the equally defensible 
hypothesis that this attitudinal 
(or at least behavioral) 
change is the result of ads 
for toothpaste, floss, and 
denture adhesive. According 
to many of these ads, it is im- 
portant for children to get 
good report cards from their 
dentists, and perhaps that is 
just what is happening. 
C. Decayed, Missing, and 

Filled Teeth 
As indicated previously, 
decayed, missing, and filled 
teeth are measures of dental 
health status, but it is only 
with some difficulty that those 
measures can be used as a 
cluster. 



The DMF index (a com- 
posite score of decayed, 
missing, or filled teeth) in- 
cludes two categories that 
reflect morbidity (decayed 
teeth and missing teeth) and 
one category that reflects 
restorative dental care (filled 
teeth). Since this last 
category actually reflects 
healthy teeth (obviously, not 
as healthy as unfilled teeth 
with no decay, but 
nonetheless teeth that do not 
at the time of examination re- 
quire health care), there is 
some question as to the 
value of the DMF index as a 
health status measure. In- 
stead of using that index, we 
shall only use its component 
parts separately. 

Some definitions must also 
be clarified before discussing 
dental morbidity. The 
presence in a tooth of a 
faulty filling, or the presence 
of decay in a filled tooth, 
results in that tooth being 
scored as a decayed tooth, 
not a filled tooth. The defini- 
tion of "filled teeth" includes 
crowns that may have been 
used because of caries, 
trauma, or the need for 
cosmetic improvements. 

Missing teeth among 
edentulous persons may 
have resulted from dental 
caries, trauma, or dental 
treatment to a health tooth 
because of other dental prob- 
lems, such as those 
associated with orthodontia 
or periodontal disease. 

We can now examine 
some of the descriptive den- 
tal health status data. Table 6 
compares the findings of the 
1960-1962 and the 
1971-1974 studies. Except 
for females 55 to 74 years of 
age, for whom no change in 
unrestored decayed teeth 
was noted, females in the 
other three age categories 
and males in all age 
categories showed a decline 
in the number of decayed 



188 



teeth. Overall, this reflected 
an approximate 1 7 percent 
decrease in decayed teeth. 
In both studies, women had 
an equal or slightly lower 
decayed tooth rate than did 
men. It is impossible to know 
how much of the reduction 
over time was due to 
increased frequency of dental 
visits, additional fluoridation 
of water supplies, increased 
usage of dentifrices with 
fluoride additives or fluorides 
applied topically otherwise, or 
changes in nutritional pat- 
terns, all of which were oc- 
curring in this 11- to 14-year 
span of time. 

From Table 7, it can be 
seen that for both sexes and 
for all age groups above 5 
years, blacks had a higher 
average number of decayed 
teeth and a higher average 
number of missing teeth. 
Also, while white males had 
higher decayed teeth rates 
than did white females, the 
other three racial/sexual com- 
parisons (white males with 
black females, black males 
with black females, and black 
males with white females) 
showed males having the 
healthier teeth (14). 

The effects of race and 
sex are more evident in 
Table 8, from which it can be 
seen that there is a greater 
discrepancy between the 
sexes among blacks for miss- 
ing teeth (females have about 
a 15 percent higher missing 
teeth rate than males) than 
there is for decayed teeth. 
Among whites the discrepan- 
cies were about the same, 
but in opposite directions for 
the two types of dental mor- 
bidity. Table 9, which com- 
pares the sex differences be- 
tween the races, shows that 
missing teeth rates were 
closer between the races and 
the sexes, whereas the decay 
rates were quite disparate. 
The disparity was noticeably 
higher among females than 
males (15). Although the 



totals included other races, 
there were too few in the 
sample to break them out as 
a separate group and too 
few to have any impact on 
the conclusions drawn. 

Table 7 also demonstrates 
the racial/sexual differences 
with respect to filled teeth. As 
indicated earlier, this is the 
only one of the three 
measures which solely 
represents use of dental care 
services, and the com- 
parisons are startling. Tables 
8 and 9 illustrate the com- 
parisons quite graphically. 
Females have a greater 
amount of restorative dental 
care than males. While the 
difference among whites 
favors females by 9 percent, 
among blacks the female rate 
runs 27 percent higher than 
the male rate. The com- 
parisons within sex but bet- 
ween races are even more 
startling. White women 
average 3.84 times more 
filled teeth than black 
women, and white males 
average 4.47 times more 
filled teeth than black males. 
These ratios seem due in 
part to the fact that blacks, 
both male and female, have 
decayed teeth in need of fill- 
ings. But these ratios are too 
large for that factor to ac- 
count for more than about 
half of the differences noted 
(16). 

If we add together 
decayed and filled teeth to 
get a measure of total dental 
caries restored and 
unrestored, we see that 
blacks have about half of the 
dental caries rate of whites 
(8.0 for white males, 8.4 for 
white females, 3.7 for black 
males, and 4.3 for black 
females). We also see that 
females have higher total 
rates than do males (white 
females 5.0 percent higher, 
black females 16.2 percent 
higher). If we now compare 
the number of filled teeth to 
this combined number, we 
have a measure of dental 



health needs met (i.e., 
F/D + F). This measure 
demonstrates that whites 
have "dental health needs 
met" scores (for dental 
caries) that are twice those of 
blacks (0.8375 for white 
males, 0.8690 for white 
females, 0.4054 for black 
males, and 0.4419 for black 
females). We also see that 
females have higher "dental 
health needs met" scores (for 
caries) than do males [(3.76 
percent higher for whites and 
9.0 percent for blacks)]. 

We can therefore con- 
clude, as has been 
concluded many times 
elsewhere in the literature, 
that blacks appear to have 
naturally healthier teeth from 
the standpoint of dental 
decay. The only explanatory 
hypotheses that seem to fit 
the known facts are those 
associated with nutrition and 
those associated with 
genetics. 

D. Periodontal Disease 

For adults over the age of 
35, periodontal disease has 
been found to be the most 
significant factor in the loss of 
teeth. That cluster of diseases 
is generally associated with 
the deterioration of the tissue 
that anchors the teeth. The 
severity of this disease varies 
from a mild inflammation of 
the supportive tissue to a 
general destruction of the 
dental foundation materials, 
including the bone matter ad- 
jacent to the dental tissue. In 
very advanced stages of 
periodontal diseases, tooth 
loss is inevitable. 

The causes of periodontal 
diseases remain unknown. It 
is suspected, however, that 
mouth bacteria and the 
presence of plaque and 
calculus play significant roles. 
This assumption is partially 
supported by studies that 
have demonstrated 
diminished periodontal 
pathology with increased 
levels of oral cleanliness (16). 



Table 10 lists the average 
periodontal index PI (a 
weighted score, by 
seriousness of disease) 
distributed by age, sex, and 
race for 1971-1974. Note that 
the prevalence of the disease 
is greater among blacks and 
among males, and that the 
prevalence increases with 
age. Racial/sexual com- 
parisons are found in Table 
11; the sexual and racial 
ratios do not vary much. The 
PI relationship associated 
with sex and race occurs 
throughout all age groups 
(15). 

The relationships between 
preventive health behaviors 
and periodontal disease are 
of some concern since they 
represent resources in addi- 
tion to dental health care that 
might help achieve dental 
health parity. No relationship 
seems to obtain for alcohol 
consumption, but two other 
variables that are related to 
periodontal disease 
(toothbrushing and smoking) 
are documented in Tables 12 
and 13. 

Table 12 shows that 
toothbrushing has a profound 
effect on PI scores. The ratio 
of the indexes for no 
brushing to brushing once a 
day is 2.53 for the mean and 
7.10 for the median. A signifi- 
cant decrease in the PI also 
occurs for the second daily 
brushing; the ratio between a 
once-daily and a twice-daily 
brushing drops to 1 .33 for 
the mean and 1.78 for the 
median. Adding a third or a 
fourth daily brushing has 
relatively little effect: 
1 .06/1 .03 are the ratios for 
the mean/median of the sec- 
ond to third brushing, and 
1.1 1/1 .55 are the ratios for 
the mean/median of the third 
to fourth brushing. But the 
fifth daily brushing again pro- 
duces a noticeable drop in 
the index (the ratio for the 
fourth to fifth brushing is 4.68 



189 



for the mean and 2.5 for the 
median). The data for the 
sixth daily brushing were 
based on examination of only 
two persons (1 7). 

Table 13 analyzes the ef- 
fects of smoking on 
periodontal disease. Three 
categories of smoking were 
used for classifying ex- 
aminees: those who had 
' never smoked, those who 
had smoked in the past and 
had since quit, and those 
who were still smoking. From 
the data in Table 13, it can 
be seen that smoking has 
both a current and perma- 
nent effect. That is, among 
those who had previously 
smoked there is an elevated 
PI score relative to those who 
never smoked, but the eleva- 
tion was slight compared to 
that for those currently smok- 
ing. The ratio of mean/me- 
dian PI scores of smokers to 
nonsmokers was 1.53/2.19 
(17). 

E. Edentulism 

A person who has lost all his 
or her teeth is called eden- 
tulous. This condition in- 
creases with advancing age 
and occurs in approximately 
half of the population over 
the age of 65. It is more 
prevalent among the white 
population than the black. 

Table 14 lists edentulous 
people by race, sex, age, 
and degree of edentulism. 
An analysis between these 
categories for totally eden- 
tulous persons (i.e., those 
with both arches edentulous) 
can be found in Table 15. 
Note that most of the racial 
differences for edentulism for 
all ages (69 percent higher 
rates for whites) disappear 
with age until there is only a 
9 percent difference between 
the races among the elderly. 
It is also true that females 
have higher edentulism rates 
than do males, but the sexual 
difference between the races 



females have rates that are 
almost three times those of 
black males, and those rates 
only drop to twice those of 
black males among the elder- 
ly (18). 

The highest differential 
ratio comes from comparing 
white and black males, for 
whom the ratio is 3.27, and 
that ratio drops to only 1.62 
among the elderly. Finally, 
although white females have 
27 percent more total eden- 
tulism than do black females, 
there is an inversion among 
the elderly, where black 
females have higher eden- 
tulism rates than do white 
females. 

Table 16 shows the 
change in edentulism rates 
that occurred over a 
13-to- 14-year period, from 
which we can see that white 
edentulism rates have been 
dropping rapidly. At that rate 
of fall, the total and female 
racial differences may have 
disappeared already, but the 
differential between white and 
black males may not disap- 
pear until the turn of the cen- 
tury (19). 

Edentulism is also related 
to other demographic 
variables. For example, it 
decreases as socioeconomic 
standing increases (Table 
1 7). The finding that in- 
dividuals of low income and 
education suffer dispropor- 
tionately from this condition is 
somewhat expected from the 
prior determinations of this 
section. They are found to 
have high susceptibility to the 
more severe forms of 
periodontal disease, which is 
the most important factor in 
tooth loss after the middle 
years of life (20). 

There is also a relationship 
between edentulism and 
utilization of dental health 



people who do not use den- 
tal services, or whether it is 
because edentulous persons 
no longer have to have den- 
tal visits, is not clear. 

The lower proportion of 
edentulous adults among the 
black population relative to 
white population is not fully 
explainable in light of the 
other dental health status 
measures presented here. 
Though blacks have been 
shown to have greater 
resistance to tooth decay, 
their demonstrated lower 
levels of periodontal health 
and oral health would seem- 
ingly enhance the probability 
of total loss. 

F. Oral Hygiene 

The technique utilized by the 
National Health Examination 
Survey to determine the 
status of its subjects' oral 
hygiene was based on the 
judgment of a dental ex- 
aminer using three measures: 
a Simplified Oral Hygiene In- 
dex (OHI-S), a Simplified 
Debris Index (Dl-S), and a 
Simplified Calculus Index 
(Cl-S). 

The first of these indexes 
is in Table 18, from which it 
can be seen that blacks have 
an appreciably higher index 
than do whites (black-to-white 
ratio = 1.67), as do males in 
comparison to females (male- 
to-female ratio = 1.35), but 
the racial differences are 
much greater than the sexual 
differences. The differential 
between the races among 



males (1.60) is less than the 
differential between the races 
among females (1.79). The 
sexual differentials are also 
greater among whites (white 
female to white male ratio = 
1 .38) than among blacks 
(black femate to black male 
ratio = 1.24). Although the 
oral hygiene index increases 
with age, the increase is 
more rapid among the 
categories with poor oral 
hygiene (blacks and males). 
That is, the differentials in 
lower age brackets are 
slighter, and increase with 
age (15). 

Tables 19 and 20 contain 
the data for the Debris and 
Calculus Indexes, arranged 
by the same variables. From 
these tables it can be seen 
that the discussion above ap- 
plies to these indexes as well 
(15). 



190 



Table 1 

Comparison of studies reporting dental services utilization data. 



1957- 1963- 
1950 1952 1953 1954 1955 1958 1958 1960 1963 1964 1965 1968 1969 1973 1974 1975 1976 1977 1981 



Study Conducted By: Year(s) in Which Study was Conducted 

1928- 1935- 1949- 
<1930 1931 1936 1949 1951 

Richards 20 — — — — 

(Estimate) 25 — — — — 

CCMC — 28 — — — 
Nat'l Hlth 

Survey — — 33 — — — — — — — 37 

ADA — — — 40 — — 42 — — 45 — 

HIF _______ 34 ___ 

GALLUP — 37 

NORC — — _______ 49 — 

HIS 

KOOS - 36 

Larson & — — — — 29 — — — — — — 

Sutton — — __ 38 — — — — — — 



43 4 49 

47 49 50 49 50 53 

37 - 38 - _________ 

_ 46 — — 46 48 — — — — — — — 

___ _ _____61- 



Note: Entries are percentage of respondents having at least one dental visit within the year reported. 

Source: "Utilization of Dental Services by Rural People in Selected New York Counties." Hay, D G , Larson, O F , and 

Sutton, D. In Journal of the American Dental Association, 47, 423-430, 1953. 



191 



Table 2 

Dental visits and interval since last visit, according to selected patient characteristics: United States, 1964, 1976, and 1981 

[Data are based on household interviews of a sample of the civilian noninstitutionalized population] 



Interval since last dental visit 



Selected 
characteristic 



Dental 

visits 



Less than 
1 year 



1 year-less 
than 2 years 



2 years 
or more 



1964 1976 1981 1964 1976 1981 1964 1976 1981 1964 1976 1981 



Never 
visited 
dentist 



1964 1976 1981 



Number per person 

Total 12 - 3 1.6 1.6 1.7 

Age 

Under 17 years 1.4 1.5 1.6 

Under 6 years 0.5 0.5 0.6 

6-16 years 2.0 1.9 2.2 

17-44 years 1.9 1.7 1.7 

45-64 years 1.7 1.8 1.8 

65 years and over .... 0.8 1.2 1.5 

Sex 1 

Male 1.4 1.5 1.6 

Female 1.7 1.7 1.8 

Race 1 ' 4 

White 1.7 1.7 1.8 

Black 5 0.9 0.9 1.1 

Family income 1,6 

Less than $7000 0.9 1.1 1.1 

S 7.000 S9.999 0.9 1.2 1.3 

$10,000-314,999 1.4 1.3 1.4 

315,000-324,999 1.9 1.4 1.7 

325,000 or more 2.8 2.1 2.2 

Geographic region 1 

Northeast 2.1 1.8 2.0 

North Central 1.6 1.6 1.7 

South 1.2 1.3 1.5 

West 1.8 1.8 1.7 

Location of residence 1 

Within SMSA 1.8 1.7 1.8 

Outside SMSA 1.2 1.3 1.4 



42.0 48.7 50.0 12.8 



41.6 50.1 50.0 

16.5 21.2 21.7 

56.9 63.2 64.7 

50.0 53.7 54.2 

38.4 46.5 49.6 

20.8 29.7 34.6 



40.0 46.7 47.9 
43.9 50.6 52.0 



44.7 51.0 52.2 

22.8 32.8 35.5 



25.8 36.1 37.0 

29.2 36.6 37.3 
39.1 40.6 42.3 
49.6 46.5 50.1 

63.3 60.8 63.5 



47.9 54.0 55.2 

44.0 51.0 52.2 

35.0 42.6 44.7 

43.3 50.0 50.3 



44.5 51.0 52.0 
37.8 43.7 45.9 



Percent of population 
13.0 13.3 28.1 26.4 



9.1 10.8 10.8 

2.3 3.5 3.5 

13.2 14.1 14.5 

17.2 16.8 17.3 

13.1 12.3 12.5 

7.7 8.0 8.0 



13.0 13.2 13.6 
12.5 12.9 12.9 



12.9 12.7 12.9 
11.7 15.3 15.0 



10.7 12.8 13.5 

12.5 14.3 14.5 

13.7 13.0 14.0 

13.4 14.2 14.0 

12.2 12.4 12.0 



12.7 12.0 12.7 
13.0 12.8 12.7 
12.0 13.3 13.3 

13.8 14.2 14.7 



24.8 



13.1 
12.1 



13.0 13.3 
13.0 13.0 



6.3 8.3 8.0 

0.6 0.7 1.0 

9.8 11.7 11.6 

27.8 26.2 25.1 

45.5 39.3 36.2 

66.8 60.9 56.1 



28.8 27.8 26.1 
27.6 25.1 23.5 



27.3 25.4 23.7 
35.3 34.4 33.1 



34.6 33.6 33.3 

34.3 33.2 32.8 

30.0 31.6 30.0 

24.9 27.3 24.4 

16.6 18.9 16.2 



25.7 24.4 22.4 

28.8 26.0 24.6 
30.0 29.5 28.1 
27.5 23.9 22.0 



26.8 24.6 23.0 
30.5 30.3 28.5 



15.6 10.8 10.9 



42.6 29.9 30.4 

80.4 74.2 73.4 

19.6 10.0 8.1 

3.2 2.1 1.9 

1.3 0.8 0.6 
1.5 0.7 0.5 



16.1 11.2 11.2 
15.1 10.6 10.6 



13.8 9.9 10.2 
27.1 16.0 14.3 



27.0 16.7 15.5 

22.0 15.1 14.3 

16.1 13.9 12.9 
11.0 11.2 10.7 

7.0 6.8 7.3 



12.7 8.6 8.7 
13.0 9.6 9.6 

20.8 13.5 12.7 
14.5 10.7 11.8 



14.3 10.3 10.5 
17.9 12.1 11.6 



'Age adjusted by the direct method to the 1970 civilian noninstitutionalized population, using 4 age intervals, 
includes all other races not shown separately, 
includes unknown family income. 

4 ln 1964 and 1976, the racial classification of persons in the National Health Interview Survey was determined by interviewer 
observation. In 1981, race was determined by asking the household respondent. 
5 1964 data are for all other races 

6 Family income categories for 1981. Adjusting for inflation, corresponding income categories in 1964 were: less than $2,000; 
$2,000-$3,999; $4,000-$6,999; $7,000-59,999; and $10,000 or more, and, in 1976 were; less than $5,000; $5,000-$6,999; 
$7.000-$9,999; $10,000-$14,999; and $15,000 or more. 

Source: Division of Health Interview Statistics, National Center for Health Statistics: Data from the National Health Interview 
Survey. In National Center for Health Statistics: Health, United States, 1983. DHHS Pub. No. (PHS) 84-1232. Public Health 
Service. Hyattsville, MD, December 1983. 



192 



Table 3 

Average annual dental visits for all persons of Hispanic ancestry according to family income and age: United States, 1976-78. 

Persons of 

All persons of Persons of Mexican- p uer t 0 Ri n Persons of Persons of Other 

Income and age Hispanic Ancestry American Ancestry Ancestry Cuban Ancestry Spanish Ancestry 



Average Annual Percent of Persons with a Dental Visit in Past Year 

All family incomes 1 
Age 



All ages 


34.7 


28.9 (1 


.20) 


41.2 (0.84) 


42.5 (0.82) 


43.1 


(0.81) 


Under 45 years .... 


35.3 


29.2 (1 


.21) 


42.5 (0.83) 


47.8 (0.74) 


44.1 


(0.80) 


45-64 years 


34.5 


29.7 (1 


.16) 


35.7 (0.97) 


39.4 (0.88) 


42.5 


(0.81) 


65 years and over . . 


23.6 


19.5 (1 


.21) 


28.6 (0.83) 


22.1 (1.07) 


30.0 


(0.79) 


Under $10,000 
















Age 
















All ages 


28.7 


21.7 (1 


.32) 


40.2 (0.71) 


37.4 (0.77) 


37.1 


(0.77) 


Under 45 years .... 


30.0 


22.2 (1 


.35) 


41.7 (0.72) 


45.1 (0.67) 


40.0 


(0 75) 


45-64 years 


25.1 


19.9 (1 


.26) 


35.2 (0.71) 


35.5 (0.71) 


26.5 


(0.95) 


65 years 


19.9 


18.3 (1 


.09) 


18.2 (1.09) 


17.9 (1.11) 


26.0 


(0.77) 


$10,000 or more 
















Age 
















All ages 


41.5 


37.2 (1 


.12) 


43.9 (0.95) 


47.1 (0.88) 


48.7 


(0.85) 


Under 45 years .... 


41.2 


36.8 (1 


.12) 


44.7 (0.92) 


50.3 (0.82) 


47.8 


(0.86) 


45-46 years 


44.5 


41.0 (1 


.09) 


38.6 (1.15) 


42.3 (1.05) 


55.7 


(0.80) 


65 years and over . . 


32.5 


25.0 (1 


.30) 


45.5 (0.71) 


31.3 (1.04) 


41.4 


(0.79) 


1_ The "all family incomes" category includes unknown income 














Note: Entries in parentheses are ratios of all Hispanics of that subgroup. Thus, ratios over 1 .0 represent lower proportions of dental 






visits for that subgroup. 
















Source; Compiled by CHESS based on tables found in National Center for Health Statistics, National Health Interview Survey, Classifica- 






tion Issues In Measuring the Health Status of Minorities July 1980 














Table 4 
















Number of dental visits per year per person for persons of Spanish ancestry by type of Spanish ancestry according to family income 


and age: United States, 


1976-78. 






















Persons of Spanish Ancestry 














Type of Spanish Ancestry 






Family income and age 


Total M 


exican American 


Puerto Rican 


Cuban 


Other Spanish 






Number of dental visits per person per year 






All incomes 
















All ages 


1.2 


0.9 




1.8 


1.6 




1.7 


Under 45 years 


1.2 


0.9 




1.6 


1.9 




1.7 


45-64 years 


1.5 


1.2 




2.2 


1.3 




1.8 


65 years and over .... 


1.0 


0.4 




4.8 


0.3 




1.3 


Under $10,000 
















All ages 


0.9 


0.6 




1.4 


1.4 




1.3 


Under 45 years 


1.0 


0.6 




1.3 


2.2 




1.4 


45-64 years 


0.8 


0.5 




2.0 


0.3 




0.8 


65 years and over .... 


0.7 


0.4 




1.5 


0.6 




1.1 


$10,000 or more 
















All ages 


1.6 


1.2 




2.0 


1.7 




2.1 


Under 45 years 


1.5 


1.2 




1.8 


1.7 




2.0 


45-64 years 


2.2 


1.8 




2.9 


2.2 




2.9 


65 years and over .... 


1.2 


0.4 




6.0 






2.2 



Note: Entries in parentheses are ratios of all Hispanics to Hispanics of that subgroup. Thus, ratios over 1 .0 represent lower propor- 
tions of dental visits. 

Source: Compiled by CHESS based on tables found in National Center for Health Statistics, National Health Interview Survey. Classifica- 
tion Issues in Measuring the Health Status of Minorities, July 1980. 



Table 5 

Percent of the population with no dental visits in the past 2 years, by poor and nonpoor status, color, and age: United States, selected 
years 1964-81. 

(Data are based on household Interviews of the civilian, nonmstitutionalized population) 



Age and year 




Total 




White 




All other 


Poor 


Nonnoor 


Poor 


Nonpoor 


Poor 


Mnnnnnr 








Percent of persons with no dental visits 






All ages 














1 964 


65.8 


40.0 


62.5 


38.4 


74.7 


58.6 


1973 


56.5 


34.6 


55.3 


33.2 


60.3 


48.8 


1976 


52.8 


32.6 


52.3 


31.4 


54.6 


44.9 


1978 


52.2 


32.1 


c -i n 
Ol .U 


0 -i r\ 

01 .U 


55.6 


42.5 


1979 


52.7 


32.5 


52.6 


31.2 


53.1 


44.0 


1980 


51 .2 


32.7 


50.6 


31.5 


53.0 


42.6 


1981 


51 .4 


32.8 


50.8 


31.5 


53.1 


42.7 


Under 1 7 years 














1 964 


73.2 


44.7 


66.6 


42.5 


82.9 


66.3 


1973 


58.3 


37.2 


55.8 


35.2 


62.2 


55.6 


1976 


52.9 


35.0 


52.5 


33.5 


53.6 


47.6 


1978 


51 .6 


35.2 


Add 


OO ~7 
JO. / 


54.3 


47.3 


1979 


50.4 


36.0 


50.0 


34.4 


50.8 


47.6 


1980 


51 .9 


36.4 


51.1 


35.1 


53.2 


45.2 


1981 


52.6 


36.6 


52.1 


35.0 


53.5 


47.1 


1 7-44 years 














1 964 


46.3 


30.1 


40.2 


28.5 


61 .3 


48.1 


1973 


38.9 


28.1 


35.9 


26.8 


48.5 


40.6 


1976 


37.4 


27.0 


35.1 


25.7 


45.1 


39.3 


1978 


36.3 


26.6 


33.0 


or a 

25.4 


45.8 


37.1 


1979 


36.6 


26.8 


34.9 


25.5 


41 .5 


37.9 


1980 


34.9 


26.5 


32.3 


25.3 


42.3 


36.8 


1981 


35.6 


26.8 


32.8 


25.4 


43.1 


37.1 


45-64 years 














1 964 


66.7 


43.6 


65.0 


42.6 


72.6 


59.7 


1 973 


61 .5 


38.3 


60.5 


37.4 


65.1 


51 .1 


1976 


60.2 


35.8 


59.2 


34.7 


64.0 


49.6 


1978 


59.7 


34.3 


58.9 


33.5 


62.3 


43.8 


1979 


60.6 


34.7 


58.9 


33.4 


66.2 


49.5 


1 980 


57.5 


34.4 


56.6 


33.2 


60.2 


47.5 


1981 


59.7 


34.5 


60.2 


33.5 


58.1 


45.0 


(i.'i years and over 














1964 


78.5 


63.5 


78.0 


62.9 


83.0 


76.6 


1973 


72.8 


55.9 


72.0 


54.7 


79.2 


76.8 


1976 


69.8 


51.8 


69.4 


50.6 


73.3 


73.1 


1978 


69.4 


50.6 


68.1 


49.8 


78.1 


64.2 


1979 


70.7 


49.3 


70.1 


48.5 


74.7 


62.0 


1980 


70.4 


50.9 


69.8 


49.8 


74.3 


68.3 


1981 


70.0 


49 9 


69.3 


48.9 


73.7 


65.3 



Note Definitions of poor and nonpoor are based on family income: 





Poor 


Nonpoor 


1964 


under $3,000 


$3,000 and over 


1973 


under $6,000 


$6,000 and over 


1976 


under $7,000 


$7,000 and over 


1978 


under $7,000 


$7,000 and over 


1979 


under $7,000 


$7,000 and over 


1980 


under $7,000 


$7,000 and over 


1981 


under $7,000 


$7,000 and over 



Source: Unpublished data from the National Health Interview Survey, National Center for Health Statistics. In "Changes in Morbidity, Disability, and Utilization Differentials be- 
tween the Poor and Nonpoor Data from Health Interview Survey: 1964 and 1973," Ronald W. Wilson and Elijah L White Reprinted from Medical Care, August 1977, Vol. 
XV, No. 8, U S A. 



194 



Table 6 

Average number of decayed (D), missing (M), and filled (F) permanent teeth per person, among adults 35-74 years of age, by sex and 

age: United States, 1960-62 and 1971-74. 

~ DMF teeth D teeth M teeth Y teeth 

Sex and age 1960-62 1971-74 1960-62 1971-74 1960-62 1971-74 1960-62 1971-74 

Average number of affected teeth per person 



Both sexes, 35-74 years 


19.1 


20.2 


1.2 


1.0 


11.2 


11.0 


6.7 


8.2 


Men 


















35-74 years 


18.5 


19.5 


1.2 


1.0 


11.2 


10.5 


6.1 


8.0 


35-44 years 


17.2 


18.4 


1.3 


1.2 


8.1 


8.4 


7.8 


8.8 


45-54 years 


18.0 


19.2 


1.3 


1.0 


10.9 


9.9 


5.8 


8.3 


55-64 years 


20.4 


20.7 


1.1 


1.0 


14.7 


12.4 


4.6 


7.3 


65-74 years 


22.3 


21.8 


0.8 


0.7 


18.1 


15.6 


3.5 


5.5 


Women 


















35-74 years 


19.7 


20.8 


1.1 


0.9 


11.3 


11.4 


7.3 


8.5 


35-44 years 


18.8 


20.0 


1.3 


1.1 


9.2 


9.8 


8.3 


9.2 


45-54 years 


19.6 


20.5 


1.1 


0.9 


11.5 


11.1 


7.0 


8.5 


55-64 years 


21.9 


21.5 


0.8 


0.8 


14.8 


12.6 


6.3 


8.1 


65-74 years 


22.8 


22.5 


0.5 


0.5 


16.8 


14.7 


5.5 


7.2 


Note; Filled teeth include only teeth with satisfactory f 


Kings. Decayed teeth include not only teeth with caries but also filled teeth 








with carious lesions or defective fillings 


Missing teeth include both missing and nonfunctional teeth. DMF is the total of these 3 









categories. 

Source: National Center for Health Statistics Decayed, Missing, and Filled Teeth Among Persons 1-74 Years, United States. Vital 
and Health Statistics, Series 11, No. 223, DHHS Pub No (PHS) 81-1673 August 1981. 



i 



Table 7 

Average number of decayed (D), missing (M), and filled (F) permanent teeth per person among persons aged 1-74 years, by race, sex, 
and age United States, 1971-74. 



DMF teeth D Teeth M teeth F teeth 

Sex and age Total 1 White Black Total 1 White Black Total 1 White Black Total 1 White Black 

Both sexes Average number of teeth 

All ages, 1-74 years . . . 13.0 13.5 9.6 1.3 1.2 2.3 5.3 5.3 5.6 6.4 7.0 1,7 

1-5 years 0 I 0 1 0 1 0 1 0.1 0.1 0.0 0.0 0.0 0.0 0.0 

6-11 years 1.7 1.7 1.6 0.7 0.6 0.9 0.1 0.1 0.3 0.8 0.9 0.5 

12-17 years 6.2 6.3 5.5 1.8 1.6 3.1 0.6 0.5 1.2 3.7 4.1 1.3 

18-44 years 14.9 15.3 12.4 1.7 1.5 3.2 4.9 4.7 6.6 8.3 9.1 2.6 

45-64 years 20.4 21.2 14.2 0.9 0.9 1.4 11.3 11.4 11.2 8.1 8.9 1.7 

65-74 years 22.2 22.5 19.9 0.6 0.5 1.1 15.2 14.9 17.8 6.4 7.0 1.0 

Male 

All ages, 1-74 years . . . 12.4 12.9 8.9 1.4 1.3 2.2 4.9 4.9 5.2 6.1 6.7 1.5 

1-5 years 0.1 0.1 0.1 0.1 0.1 0.1 0.0 0.0 

6-11 years 1.6 1.6 1.5 0.7 0.7 0.9 0.2 0.1 0.3 0.7 0.8 0.3 

12-17 years 5.7 5.8 5.1 1.7 1.5 3.0 0.5 0.4 0.9 3.5 3.9 1.2 

18-44 years 14.4 14.8 11.8 1.8 1.6 3.2 4.5 4.4 6.1 8.1 8.8 2.5 

45-64 years 19.8 20.7 12.7 1.0 1.0 1.1 11.0 11.1 10.4 7.9 8.7 1.2 

65-74 years 21.9 22.3 19.5 0.7 0.6 1.2 15.7 15.5 17.5 5.5 6.1 0.8 

Female 

All ages 1-74 years 13.5 14.0 10.3 1.3 1.1 2.4 5.6 5.6 6.0 6.6 7.3 1.9 

1-5 years 0.1 0.1 0.2 0.1 0.0 0.2 0.0 0.0 0.0 

6-11 years 1.7 1.7 1.8 0.7 0.6 1.0 0.1 0.1 0.2 1.0 1.0 0.6 

12-17 years 6.6 6.7 6.0 1.9 1.7 3.1 0.8 0.7 1.5 3.9 4.4 1.3 

18-44 years 15.3 15.7 12.8 1.6 1.4 3.1 5.2 5.0 7.0 8.5 9.4 2.7 

45-64 years 20.9 21.6 15.7 0.9 0.8 1.7 11.7 11.7 11.9 8.3 9.1 2.2 

65-74 years 22.5 22.7 20.3 0.5 0.4 0.9 14.8 14.5 18.3 7.2 7.7 1.1 



includes data for "other races," which are not shown separately 

Note: Filled teeth include only those with satisfactory fillings. Decayed teeth Include not only teeth with caries but also filled teeth 
with carious lesions or defective fillings. Missing teeth include both missing and nonfunctional teeth DMF is the total of these 3 
categories 

Edentulous persons (lost all their natural teeth) were included in this table 

Source: National Center for Health Statistics: Basic Data on Dental Examination Findings of Persons 1-74 years. United States, 
1971-1974, Vital and Health Statistics, Series 11, No 214. DHEW Pub No (PHS) 79-1662. May 1979 



196 



Table 8 

Female-to-male ratios of average decayed (D), missing (M), and filled 
(F) teeth, by race. 

D Teeth M Teeth F Feeth 

Total 0.93 1.14 1 08 



Table 9 

White-to-black ratios of average decayed (D), missing (M), and filled 
(F) teeth, by sex. 

D Teeth M Teeth F Teeth 

Male 0.59 0.94 4.47 



White 085 1/14 1.09 Female 0_46 093 3.84 

g| ac ^ 1 09 115 1 27 Source: Tabulated by CHESS from data contained In Table 7. 

Source: Tabulated by CHESS from data contained in Table 7 



Table 10 

Average Periodontal Index (PI) for persons aged 6-74 years, by race, sex, and age: United States 



1971-74. 

Sex and age Total 1 White Black 

Both sexes PI 

All ages, 6-74 years 0.83 07(3 1_28 

6-11 years 0.1 1 0.11 0.12 

12-17 years 0.32 0.29 0.53 

18-44 years 0.76 0.69 1.26 

45-64 years 1.57 1.42 2.78 

65-74 years 2.34 2.17 3.82 

Male 

All ages, 6-74 years 0.96 0_88 1^52 

6-11 years 0.14 0.14 0.15 

12-17 years 0.38 0.35 0.58 

18-44 years 0.91 0.83 1.57 

45-64 years 1.79 1.61 3.21 

65-74 years 2.81 2.61 4.20 

Female 

All ages 6-74 years 0.70 065 UT7 

6-11 years 0.08 0.08 0.10 

12-17 years 0.26 0.22 0.47 

18-44 years 0.61 0.56 1.02 

45-64 years 1.37 1.24 2.37 

65-74 years 1.96 1 .83 3.40 



''Includes data for "other races," which are not shown separately. 

Note: Edentulous persons (lost all their natural teeth) have been included in this table 

Source: National Center for Health Statistics: Basic Data on Dental Examination Findings of Persons 1-74 years. United States, 
1971-1974, Vital and Health Statistics, Series 11, DHEW Pub No (PHS) 79-1662 May 1979. 

Table 11 

Racial/sexual ratios of periodontal indexes. 

Female-to-male ratios White-to-black ratios 

White Black Male Female 

0.74 0_70 0_58 0.61 

Source: Tabulated by CHESS Staff from data contained in Table 10 



197 



rable 12 

Average and median periodontal index (PI) scores per person among persons ages 25-74 years, by 
toothbrushing frequency, with standard errors and sample sizes: United States, 1971-74. 



Standard 

Number error of 

Daily tooth-brushing frequency examined Mean PI Median PI mean 

All frequencies 2,903 1.27 0.41 0.05 

Zero 152 3.54 4.05 0.32 

One 1.180 1.40 0.57 0.06 

Two 1,294 1.05 0.32 0.06 

Three 237 0.99 0.31 0.10 

Four 28 0.89 0.20 0.04 

Five 10 0.19 0.08 0.13 

Six 2 0.00 0.00 0.00 



Source: National Center for Health Statistics: Diet and Dental Health, A Study of Relationships: United States, 1971-1974. DHHS 
Pub No (PHS) 82-1675. Series 11, Data from the National Health Survey; No 225 Hyattsville, MD January 1982. 



Table 13 

Average and median periodontal index (PI) scores per person among persons aged 25-74 years, by 
smoking history, with standard errors and sample sizes: United States, 1971-74. 



Standard 

Number error of 
Smoking history examined Mean PI Median PI mean 

All subjects .. . 2,948 1.28 0.42 0.05 

Never 1,104 1.01 0.31 0.07 

Past 516 1.10 0.34 0.08 

Now 1,328 1.55 0.68 0.08 



Source National Center for Health Statistics: Diet and Dental Health, A Study of Relationships; United States. 1971-1974. DHHS 
Pub No (PHS) 82-1675. Series 11, Data from the National Health Survey, No 225. Hyattsville. MD, January 1982. 



198 



Table 14 

Percent distribution of adults 18-74 years of age, by number of edentulous arches, according to race, sex, and age, with standard errors 
of the percent: United States, 1971-74. 







With 




With 






With 




With 






no 


With 1 


both 






no 


With 1 


both 






arch 


arch 


arches 






arch 


arch 


arches 


Sex and age 


Total 


edentu- 


edentu- 


edentu- 


Sex and age 


Total 


edentu- 


edentu- 


edentu- 






lous 


lous 


lous 






lous 


lous 


lous 




White 










Black 












Percent 








Percent 




Both sexes 




distribution 




Both sexes 




distribution 




All ages, 18-74 years 


100.0 


75.2 


9.4 


15.4 


All ages, 18-74 years 


100.0 


82.8 


8.1 


9.1 


18-24 years 


100.0 


98.0 


1.3 


*0.7 


18-24 years 


100.0 


98.5 


M.4 


"0.1 


25-34 years 


100.0 


y I .O 


D.H 


3.3 


25-34 years 


100.0 


Q9 A 


* A 7 


*2.9 


35-44 years 


100.0 


79.8 


10.8 


9.5 


35-44 years 


100.0 


82.2 


* 1 1 .6 


6.2 


45-54 years 


100.0 


69.3 


13.6 


17.1 


45-54 years 


100.0 


83.9 


*8.8 


*7.3 


55-64 years 


100.0 


51.1 


14.2 


34.7 


55-64 years 


100.0 


67.0 


"13.3 


19.8 


65-74 years 


100.0 


38.8 


15.2 


45.9 


65-74 years 


100.0 


40.7 


17.1 


42.3 


Men 










Men 










All ages, 18-74 years 


100.0 


77.3 


8.2 


14.4 


All ages, 18-74 years 


100.0 


88.9 


*6.7 


4.4 


18-24 years 


100.0 


98.0 


•1.2 


*0.8 


18-24 years 


100.0 


99.7 


*0.3 




25-34 years 


100.0 


92.6 


*4.4 


*2.9 


25-34 years 


100.0 


95.8 


*4.2 


— 


35-44 years 


100.0 


83.4 


8.5 


8.1 


35-44 years 


100.0 


88.6 


*8.0 


*3.4 


45-54 years 


100.0 


72.1 


11.3 


16.6 


45-54 years 


100.0 


92.2 


"6.1 


"1.7 


55-64 years 


100.0 


52.4 


13.9 


33.6 


55-64 years 


100.0 


75.3 


M5.3 


*9.4 


65-74 years 


100.0 


39.4 


15.5 


45.1 


65-74 years 


100.0 


56.0 


16.2 


27.9 


Women 










Women 










All ages, 18-74 years 


100.0 


73.2 


10.4 


16.3 


All ages, 18-74 years 


100.0 


78.1 


9.1 


12.8 


18-24 years 


100.0 


97.9 


*1.4 


*0.6 


18-24 years 


100.0 


97.6 


*2.3 


*0.1 


25-34 years 


100.0 


90.0 


6.3 


3.6 


25-34 years 


100.0 


89.8 


"5.1 


*5.1 


35-44 years 


100.0 


76.3 


12.9 


10.8 


35-44 years 


100.0 


77.2 


14.4 


*8.3 


45-54 years 


100.0 


66.8 


15.7 


17.5 


45-54 years 


100.0 


76.8 


M1.2 


*12.0 


55-64 years 


100.0 


49.9 


14.4 


35.6 


55-64 years 


100.0 


60.3 


M1.6 


*28.1 


65-74 years 


100.0 


38.4 


15.1 


46.5 


65-74 years 


100.0 


29.2 


17.7 


63.0 



Note: Where an asterisk (*) is printed next to the cell value, the number of cases for that cell was less than 30 or the relative standard 
error for the cell value was 26 percent or more. 

Source: Compiled by CHESS from National Center for Health Statistics: Decayed, Missing and Filled Teeth Among Persons 1-74 
years: United States DHHS Pub. No (PHS) 81-1673. Series 11, Data from the National Health Survey, No. 223. Tables 10 and 
11, pp. 28-29 

Hyattsville, MD, August 1981 

Table 15 

Comparison of edentulism ratios as a function of race, sex, and age. 



Comparison Categories Ratios 





M\ ages 


65-74 years of age 


White to black 


1.69 


1.09 


White female to white male 


1.13 


1.03 


Black female to black male 


2.91 


1.90 


White male to black male 


3.27 


1.62 


White female to black female 


1.27 


0.88 



Source: Tabulated by CHESS from data contained in Table 14. 



199 



Table 16 

Percent of white and all other edentulous persons 45 years and over in the population, by sex and 
age: United States, July 1957-June 1958 and 1971. 

White All other 1 



July 1957- July 1957- 

Sex and age June 1958 1971 June 1858 1971 



Both sexes Percent 



45 years and over 




39.4 


32.7 


23.3 


24.1 






45-64 years 




30.3 


23.9 


17.0 


17.2 






65 years and over 




60.6 


51.4 


43.1 


42.9 






Male 
















45 years and over 




37.4 


31.5 


19.3 


18.7 






45-64 years 




29.3 


23.7 


13.5 


12.4 






65 years and over 




57.3 


50.3 


37.5 


35.5 






Female 
















45 years and over 




41.3 


33.8 


27.1 


29.1 






45-64 years 




31.3 


24.1 


20.3 


21.3 






65 years and over 




63.3 


52.3 


48.2 


48.7 






1 Figures for black persons have been combined with those tor persons of races other than white to facilitate comparison between 






the 1971 estimates and those obtained in the July 1957-June 1958 survey 










Source: National Center for Health Statistics: Edentulous Persons, United States, 1971 


DHEW Pub. No (HRA) 74-1516 Series 






10, Data from the National Health Survey, No 


89 Rockville, MD, June 1974. 










Table 17 
















Percent of edentulous persons by income level and age, U.S., 1971. 
















Family Income 


$ 










3,000- 


5,000- 


7,000- 


10,000- 


15,000 or 


All 


Age, Years 


<3,000 


4,999 


6,999 


9,999 


14,999 


More 


Incomes 


All Ages 


25.7 


18.1 


11.9 


9.7 


7.0 


5.2 


1 1 .2 


Under 25 








* 






0.1 


25-44 


7.9 


8.0 


7.6 


7.7 


5.8 


3.7 


6.3 


45-64 


33.5 


32.4 


28.0 


27.4 


20.7 


11.7 


23.3 


65 or More 


58.5 


53.2 


46.2 


47.3 


42.0 


35.2 


50.7 


Percent of edentulous persons by educational level and age, U.S., 


1971. 
















Educational Level 








Age, Years 


All 




9-11 


12 


13 Years 








Levels 


<9 years 


Years 


Years 


or More 






All Ages (Yrs.) 


11.2 


36.9 


17.6 


11.1 


5.9 






Under 25 


0.1 






0.5 








25-44 


6.3 


11.3 


11.4 


6.1 


1.6 






45-64 


23.3 


34.3 


28.7 


19.0 


10.6 






65 or More 


50.7 


58.0 


51.1 


42.4 


30.8 







* Figure does not meet standards of reliability or precision 

Source National Center for Health Statistics. Edentulous Persons, United States, 1971 DHEW Pub No (HRA) 74-1516. Series 
10, Data from the National Health Survey No 89 Rockville, MD, June 1974. 



200 



Table 18 

Average Simplified Oral Hygiene Index (OHI-S) for persons aged 
6-74 years, by race, sex, and age, United States: 1971-74. 

Sex and age Total 1 White Black 

Both sexes OHI-S 



includes data for "other" races, which are not shown separately 

Note: Those persons with missing data or without at least two of the six teeth used 

for OHI-S have been excluded from this table. 

Source: Abstracted by CHESS from National Center for Health Statistics: Basic Data 
on Dental Examination Findings of Persons 1-74 Years: United States, 1971-1974. 
DHEW Pub. No. (PHS) 79-1662. Series 1 1 , Data from the National Health Survey. No 
214. Hyattsville, MD, May 1979. 



Table 19 



Average Simplified Debris Index (Dl-S) for persons aged 6-74 years, 
by race, sex, and age: United States, 1971-74. 


Sex and age 


Total 1 


White 


Black 


Both sexes 




Dl-S 




All ages, 6-74 years 


0.66 


0.62 


0.94 


6-11 years 


0.72 


0.70 


0.84 


12-17 years 


0.74 


0.70 


0.98 


1 Q A A wQoro 




U.Of 


(~\ DO 

u.oy 


40-04 ytJdrS 


.... U.04 


n en 
U.oU 


I .Uo 






U. / 1 


I .do 


Male 








All ages, 6-74 years 


0.75 


0.71 


1.02 


6-1 1 years 


0.78 


0.76 


0.86 


12-1 7 years 


0.82 


0.79 


1.02 


1 Q A A \/Qoro 

I 0-44 ytidr S 


.... u.oy 


U.DD 


n qq 

u.yts 


^d-oh years 


.... U. / O 


U. 1 U 


I d-d 


do- / 4 years 


.... u.y^i 


U.OD 


I .41 


Porn J3l<=> 








All ages, 6-74 years 


0.57 


0.53 


0.86 


6-1 1 years 


0.66 


0.63 


0.82 


12-17 years 


0.65 


0.60 


0.94 


18-44 years 


0.53 


0.48 


0.82 


45-64 years 


0.53 


0.49 


0.89 


65-74 years 


. . . . 0.61 


0.58 


1.01 



'Includes data for "other" races, which are not shown separately. 

Note: Those persons with missing data or without at least two of the six teeth used 

for Dl-S have been excluded from this table. 

Source: National Center for Health Statistics: Basic Data on Dental Examination Find- 
ings of Persons 1-74 Years, United States. 1971-1974. DHEW Pub. No. (PHS) 79-1662. 
Series 1 1 , Data from the National Health Survey, No. 214, Hyattsville, MD, May 1979. 



All ages, 6-74 years 100 0.93 1.56 

6-11 years 0.75 0.72 0.88 

12-17 years 0.89 0.82 1.34 

18-44 years 1.01 0.93 1.62 

45-64 years 1.23 1.10 2.27 

65-74 years 1.43 1.33 2.56 

Male 

All ages, 6-74 years 1.16 1.08 1.73 

6-11 years 0.80 0.78 0.90 

12-17 years 1.00 0.92 1.43 

18-44 years 1.16 1.09 1.82 

45-64 years 1.46 1.32 2.64 

65-74 years 1.76 1.64 2.84 

Female 

All ages, 6-74 years 0.86 0.78 1.40 

6-11 years 0.69 0.66 0.86 

12-17 years 0.80 0.72 1.25 

18-44 years 0.86 0.77 1.46 

45-64 years 1.00 0.89 1.88 

65-74 years 1.16 1.08 2.19 



201 



Table 20 

Average Simplified Calculus Index (Cl-S) for persons aged 6-74 years, by race, sex, and age with stand- 
ard errors: United States, 1971-74. 



Sex and age 


Total 1 


White 


Black 


Total 1 


White 


Black 


Both sexes 




Cl-S 






Standard error 




All ages, 6-74 years 


0.35 


0.32 


0.62 


0.02 


0.02 


0.03 


6-11 years 


0.03 


0.03 


0.04 


0.01 


0.01 


0.01 


12-17 years 


0.16 


0.12 


0.36 


0.02 


0.02 


0.05 


1 8-44 vpars 


0 40 


0.36 


0.73 


0.02 


0.02 


0.03 


45-64 vpars 


0 58 


0.51 


1 .21 


0.03 


0.03 


0.07 


65-74 years 


0 68 


0.62 


1 .32 


0.04 


0.04 


0.1 1 


Male 














All ages, 6-74 years 


0.41 


0.37 


0.72 


0.02 


0.02 


0.03 


6-1 1 years 


0.03 


0.02 


0.04 


0.01 


0.01 


0.01 


12-17 years 


0.17 


0.13 


0.41 


0.02 


0.02 


0.07 


18-44 vpars 


0 47 


0.43 


0.84 


0.03 


0.03 


0.04 


45-64 vpars 


0 70 


0.62 


1 .42 


0.04 


0.04 


0.1 1 


65-74 years 


0 84 


0.78 


1 .43 


0.04 


0.04 


0.13 


Female 














All ages, 6-74 years 


0.30 


0.26 


0.54 


0.02 


0.02 


0.03 


6-1 1 years 


0.03 


0.03 


0.05 


0.01 


0.01 


0.02 


1 2-1 7 years 


0.14 


0.12 


0.32 


0.02 


0.02 


0.05 


18-44 years 


0.33 


0.29 


0.64 


0.02 


0.02 


0.04 


45-64 years 


0.47 


0.40 


0.99 


0.03 


0.03 


0.11 


65-74 years 


. . . 0.55 


0.50 


1.18 


0.05 


0.05 


0.13 



'Includes data for "other" races, which are not shown separately 

Note; Those persons with missing data or without at least two of the six teeth used for Cl-S have been excluded from this table. 
Source: National Center for Health Statistics: Basic Data on Dental Examination Findings of Persons 1-74 Years, United States, 
1971-1974, DHEW Pub. No. (PHS) 79-1662, Series 11, Data from the National Health Survey, No 214, Hyattsville, MD, May 1979. 



202 



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In Social Sciences and Den- 
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Richards, N.D. and Cohen, 
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10. Hay, D.G., Larson, O.F., 
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People in Selected New York 
Counties." Journal of the 
American Dental Association, 
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(PHS) 82-1566. Public Health 
Service. Washington, DC, 
U.S. Government Printing Of- 
fice, April 1982. 

12. Feller, F. and Drury T.: 
Division of Health Interview 
Statistics, "Using National 
Health Statistics for All Per- 
sons of Hispanic Ancestry As 
Surrogate Estimates for Per- 
sons of Specific Types of 
Hispanic Ancestry: A 
Preliminary Assessment of 
Problems of Bias," In 
Classification Issues in 
Measuring the Health Status 
of Minorities. U.S. Dept. of 
Health and Human Services. 
National Center for Health 
Statistics, July 1980. 

13. Kelly, J.R.: Basic data on 
dental examination findings of 
persons 1-74 years, United 
States, 1971-1974. Vital and 
Health Statistics, Series 1 1 , 
No. 214. DHEW Pub. No. 
(PHS) 79-1662. Public Health 
Service. Hyattsville, MD, May 
1979. 

14. Harvey, C.R.: Decayed, 
Missing, and Filled Teeth 
Among Persons 1-74 years. 
United States, 1971-74., Vital 
and Health Statistics, Series 
11, No. 223, DHHS Pub. No. 
(PHS) 81-1673. Public Health 
Service. Hyattsville, MD, 
August 1981. 

15. Kelly, J.R.: Basic data on 
dental examination findings of 
persons 1-74 years, United 
States, 1971-1974. Vital and 
Health Statistics, Series 1 1 , 
No. 214. DHEW Pub. No. 
(PHS) 79-1662. Public Health 
Service. Hyattsville, MD, May 
1979. 



16. McMillan, R.S., and 
Wolff, A.: "Periodontal 
Disease" In The 
Epidemiology of Oral Health 
Harvard University Press, 
Cambridge, MA, 1969. 

17. Diet and Dental Health, 
A Study of Relationships: 
United States, 1971-74. Vital 
and Health Statistics, Series 
11, No. 225. DHHS Pub. No. 
82-1675. National Center for 
Health Statistics. Hyattsville, 
MD, January 1982. 

18. Harvey, OR.: Decayed, 
Missing, and Filled Teeth 
Among Persons 1-74 years. 
United States, 1971-74. Vital 
and Health Statistics, Series 
11, No. 223. DHHS Pub. No. 
(PHS) 81-1673. Public Health 
Service. Hyattsville, MD, 
August 1981. 

19. U.S. Department of 
Health, Education, and 
Welfare. Edentulous Persons: 
U.S. 1971 , National Center 
for Health Statistics, Series 
10, No. 89, Washington, DC, 
June 1974. 

20. Selected Dental Findings 
in Adults by Age, Race, and 
Sex, United States, 1960-62. 
Vital and Health Statistics, 
Series 11, No. 7. DHEW 
Pub. No. (PHS) 79-1662. 
U.S. Department of Health 
and Human Services. Na- 
tional Center for Health 
Statistics. Hyattsville, MD, Ju- 
ly 1980. 



List of Tables 

1. Comparison of studies 
reporting dental services 
utilization data. 

2. Dental visits and interval 
since last visit, according to 
selected patient 
characteristics: United States, 
1964, 1976, and 1981. 

3. Average annual dental 
visits for all persons of 
Hispanic ancestry according 
to family income and age: 
United States, 1976-78. 

4. Number of dental visits 
per year per person for per- 
sons of Spanish ancestry by 
type of Spanish ancestry ac- 
cording to family income and 
age: United States, 1976-78. 

5. Percent of the population 
with no dental visits in the 
past 2 years, by poor and 
nonpoor status, color, and 
age: United States, selected 
years 1964-1981. 

6. Average number of 
decayed (D), missing (M), 
and filled (F) permanent teeth 
per person, among adults 
35-74 years of age, by sex 
and age: United States, 
1960-62 and 1971-74. 

7. Average number of 
decayed (D), missing (M), 
and filled (F) permanent teeth 
per person among persons 
aged 1-74 years, by race, 
sex, and age, United States, 
1971-74. 

8. Female-to-male ratios of 
average decayed (D), miss- 
ing (M), and filled (F) teeth, 
by race. 

9. White-to-black ratios of 
average decayed (D), miss- 
ing (M), and filled (F) teeth, 
by sex. 

10. Average Periodontal In- 
dex (PI) for persons aged 
6-74 years, by race, sex, and 
age: United States, 1971-74, 

1 1 . Racial/sexual ratios of 
periodontal indexes. 

12. Average and median 
periodontal index (PI) scores 
per person among persons 



203 



aged 25-74 years, by 
toothbrushing frequency, with 
standard errors and sample 
sizes: United States, 1971-74. 

13. Average and median 
periodontal index (PI) scores 
per person among persons 
aged 25-74 years, by smok- 
ing history, with standard er- 
rors and sample sizes: United 
States, 1971-74. 

14. Percent distribution of 
adults 18-74 years of age, by 
number of edentulous 
arches, according to race, 
sex, and age, with standard 
errors of the percent: United 
States, 1971-74. 

15. Comparison of eden- 
tulism ratios as a function of 
race, sex, and age. 

16. Percent of white and all 
other edentulous persons 45 
years and over in the popula- 
tion, by sex and age: United 
States, July 1957-June 1958 
and 1971. 

17. Percent of edentulous 
persons by income level and 
age, U.S., 1971. 

18. Average Simplified Oral 
Hygiene Index (OHI-S) for 
persons aged 6-74 years, by 
race, sex, and age: United 
States, 1971-74. 

19. Average Simplified 
Debris Index (Dl-S) for per- 
sons aged 6-74 years, by 
race, sex, and age: United 
States, 1971-74. 

20. Average Simplified 
Calculus Index (Cl-S) for per- 
sons aged 6-74 years, by 
race, sex, and age, with 
standard errors: United 
States, 1971-74. 



List of Figures 

IA. Unadjusted and age- 
adjusted percent of popula- 
tion with a dental visit within 
a year of interview, by family 
income: United States, 1978 
and 1979. 

IB. Unadjusted and age- 
adjusted percent of popula- 
tion with a dental visit within 
a year of interview, by 
education of head of family: 
United States, 1978 and 
1979. 



204 



Chapter IX 



Preventive Health 



Table of Contents 



Overview 207 

A. Introduction 207 

B. Preventive Examinations 208 

1. General Checkup Examinations 208 

2. Preventive Medical Procedures 208 

3. Prenatal Examinations 209 

C. Immunization 211 

D. Overall Health Assessment 212 

E. Lifestyles 212 

1. Cigarette Smoking 212 

2. Alcohol Consumption 213 

3. Obesity (Overweight) 213 
Tables 215 

References 226 
List of Tables 226 
List of Figures 227 



206 



Chapter IX 



Preventive Health 



Overview 

In this chapter the preventive 
health practices of the disad- 
vantaged are compared with 
those of the rest of the 
population. For purposes of 
this analysis, two areas of 
preventive health are in- 
cluded. First, data pertaining 
to preventive medical care, 
including routine physical ex- 
aminations, preventive 
medical procedures, and 
prenatal care, are discussed. 
Second, nonmedical personal 
habits that affect health are 
examined. 

The impetus for promoting 
preventive health appears to 
be stronger today than ever 
before. The medical com- 
munity is moving toward a 
new perspective on health- 
prevention and early detec- 
tion of disease— in addition to 
ordinary diagnosis and treat- 
ment. The Federal Govern- 
ment has identified preven- 
tive health objectives to be 
reached by the year 1990 
and, where appropriate, 
these are included 
throughout the chapter. 

One of the most telling 
measures of the population's 
enthusiasm for preventive 
care is the number of people 
who obtain a routine general 
checkup each year. Whether 
or not individuals obtain 
regular checkup examina- 
tions seems to be most 
related to education. A far 
greater proportion of the 
more educated had general 
checkups during 1980. More 
females than males reported 
having had an exam. The 
proportions were about equal 
for blacks and whites who 
had had a routine examina- 
tion in the past year. 

Racial, sex, and income 
differentials were greater than 
age differentials for medical 



procedures selectively ad- 
ministered during general 
examinations. With the 
exception of female internal 
examinations, a larger pro- 
portion of blacks than whites, 
and males than females, 
received all the other medical 
procedures during a general 
examination. For about half 
of the procedures, the non- 
poor and the poor very much 
resembled each other in their 
receipt of care; however a 
greater proportion of the non- 
poor were administered the 
remaining procedures. 

The proportion of preg- 
nant women beginning 
prenatal care in their first 
trimester of pregnancy varies 
considerably among the 
population's ethnic and racial 
subgroups, a much higher 
proportion of white mothers 
began prenatal care in their 
first trimester compared to 
blacks and Hispanics. The 
median number of physician 
visits for prenatal care was 
one visit higher for whites 
than blacks, and two visits 
higher for whites than 
Hispanics. Prenatal care 
among the various Hispanic 
population groups varied 
widely, but Puerto Rican 
mothers consistently had the 
lowest rates of prenatal care 
visits, with medical care 
sought late into their 
pregnancies, and Cuban 
women had the highest 
number of visits, with over 80 
percent of the women mak- 
ing physician visits in the first 
trimester. Prenatal care in- 
cludes several technologically 
advanced interventions that 
are primarily meant to assess 
fetal well-being. The most 
prevalent ones include am- 
niocentesis, ultrasound, and 
xrays. Among mothers 35 
years of age and over with 
live births during 1980, 
almost twice as many white 
mothers as black mothers 
had amniocentesis during 



pregnancy; approximately 
one third of all mothers had 
ultrasound, with about equal 
distribution between white 
and black mothers; only 
about 13 percent of mothers 
received at least one medical 
xray during pregnancy, and 
about 5 percent of these 
mothers potentially could 
have instead received 
ultrasound. 

The vast majority of 
children are immunized 
against the major childhood 
diseases by the time they 
enter school. The main con- 
cern is protecting preschool 
children, especially the 
residents of large inner cities. 
These usually include a 
preponderance of blacks and 
the poor. 

A great majority of 
Americans assessed their 
health in 1981 as good or 
excellent. Data from the Na- 
tional Health Interview Survey 
reported that of the white 
population, only 10.8 percent 
reported fair or poor health 
for 1981, compared with 19.7 
percent for the black 
population. 

The smoking, diet, and 
drinking habits of the disad- 
vantaged are compared 
with those of the rest of the 
population. Proportionately 
fewer adults were smoking 
in 1980 than in the past 15 
years. The most significant 
decrease in smoking 
occurred among men. In 
1980, a greater proportion 
of black males smoked 
compared to white males; 
the proportions of smokers 
among black females and 
white females were about 
equal. The numbers of 
cigarettes smoked by these 
groups, however, differed 



widely. More blacks 
smoked than whites, but 
blacks smoked far fewer 
cigarettes per day than 
whites. 

Alcohol consumption has 
not shown the same decline 
as has cigarette smoking. 
Presently, proportionately 
more whites than blacks 
consume alcohol, but 
trends in the data indicate 
that blacks are approaching 
the same alcohol consump- 
tion levels as whites. 

More females than males 
are obese or overweight. 
This is particularly true 
among black females who 
tend toward large weight 
gains following 
adolescence. 

A. Introduction 

Health care in this country is 
still, for the most part, 
organized along curative and 
reparative lines. Cure rates 
and repair rates have 
become the conventional 
criteria for success. We have 
invested most of our attention 
and an overwhelming share 
of our resources into improv- 
ing the availability and quality 
of treatment and rehabilitation 
services .... The time has 
come for us to turn our atten- 
tion as a Nation to the 
preservation of good health, 
the promotion and enhance- 
ment of healthful lifestyles, 
and the prevention of disease 
and disability (1 , p. iv). 

It should not be inferred 
from the recent popularity of 
preventive medicine that the 
subject has been neglected 
or ignored in the past. 
Because of concerted efforts 
theretofore in this area, 
poliomyelitis, malaria, cholera. 



207 



tuberculosis, etc., are now 
rare diseases. With today's 
elevated interest in preven- 
tion, there is the prospect of 
also eliminating or greatly 
reducing the incidence of 
heart disease, cancer, stroke, 
and accidents, which are to- 
day the major causes of 
death and chronic 
debilitation. 

"By definition in the con- 
text of health, prevention re- 
quires action to reduce or 
eliminate risk of exposure 
that would increase the 
chances for an individual or 
group to incur disease, 
disability, or untimely death. 
Prevention also includes 
discovering and controlling 
abnormal conditions soon 
enough to minimize 
dangerous consequences." 
(2, p. 267). 

The Federal Government 
has recognized the need for 
action, and has developed 
specific action steps toward 
realizing the five major goals 
for achieving better health 
first published in 1979 in 
Healthy People: The Surgeon 
General's Report on Health 
Promotion and Disease 
Prevention That publication 
also identified 15 priority 
areas of health promotion, 
health protection, and 
disease prevention in which 
more programmatic efforts 
would lead to the attainment 
of the major goals. In 1980, 
the Public Health Service 
published Promoting 
Health/Preventing Disease: 
Objectives for the Nation, in 
which 226 objectives are 
identified and grouped within 
the 15 specific subject areas. 
These two publications 
culminated in an action docu- 
ment entitled Implementation 
Plans for Attaining the Objec- 
tives for the Nation. "This 
document represents yet 



another step on the road 
toward realization of the 
goals and the objectives. 
Each objective presented in 
this volume is accompanied 
by an implementation plan 
that sets out specific action 
steps Federal agencies will 
be taking to contribute to 
their attainment. The objec- 
tives and their implementation 
plans are presented within 
each of the 15 priority areas 
identified ..." (3, p. 3) When 
appropriate, this chapter cites 
the 1990 objectives for the 
health conditions we discuss. 

The 1983 edition of 
Health, United States in- 
cludes a prevention profile 
which gives a great deal of 
attention to these objectives. 
Of particular interest are cur- 
rent baseline data which, in 
turn, emphasize what needs 
to be accomplished in order 
to meet the 1990 objectives. 

In this chapter the preven- 
tive health experience of the 
disadvantaged is compared 
with that of the rest of the 
population. The utilization of 
preventive medical services 
and nonmedical behavior 
patterns that are believed to 
affect health status are 
included. 

The National Center for 
Health Statistics collects infor- 
mation regarding routine 
general checkup examina- 
tions, and selected medical 
procedures such as car- 
diograms, chest xrays, vision 
tests, and female internal ex- 
ams. Demographic data are 
available to facilitate a com- 
parison of the disadvantaged 
with the remainder of the 
population. Immunization 
levels are included in this 
chapter. Selected lifestyle pat- 
terns that affect health are 
also discussed. 



B. Preventive 
Examinations 

1. General Checkup 
Procedures 

Health Interview Survey 
respondents regularly are 
asked if they visited a physi- 
cian for a general checkup 
during the past 12 months. In 
Table 1, responses to this 
question by selected 
characteristics are presented. 

Whether or not a person 
had a general checkup dur- 
ing the year appeared to be 
most related to education. 
Large differentials occurred 
among education groups. 
About 49 percent of persons 
with 16 years' or more 
education had yearly physical 
checkups, compared with 
29.4 percent of persons with 
less than 9 years' education. 

A larger proportion of 
females (44.4 percent) than 
males (33.8 percent) saw a 
physician for a general 
checkup during the year. The 
proportion of blacks who ob- 
tained a general examination 
through the year (42.2 per- 
cent) was very similar to the 
proportion of whites (41.3 
percent). 

In the first edition of this 
book, a table similar to Table 
1 was presented. That table, 
using 1971 data, showed a 
general checkup to be highly 
related to race, income, and 
education. At that time, a 
larger proportion of whites 
(40 percent) than nonwhites 
(33 percent) obtained a 
checkup; a much larger pro- 
portion of persons in the 
highest reported income 
group (52 percent) had a 
yearly checkup than persons 
in the lowest reported income 
group (27 percent); and a far 
greater proportion of persons 
with the reported highest 
level of education compared 
with those with the reported 
lowest level of education had 
yearly checkups. Although 
the proportion of the general 



population receiving preven- 
tive checkup examinations re- 
mained unchanged from 
1971 to 1980, the changes 
among the subgroups were 
dramatic. Of the 
demographic variables that 
showed a differential effect 
for obtaining a checkup in 
1971 , race has been 
eliminated, and so has in- 
come (except for the lowest 
income level, less than 
$5,000). The remaining 
variable, then, is education 
level, and that variable shows 
signs of compressions of 
range that usually precede 
the disappearance of a 
variable of impact. Oddly 
enough, the sexual variable 
is the only demographic 
characteristic that showed an 
expansion of range, and that 
effect was achieved in two 
ways: a decrease in the pro- 
portion of males and an in- 
crease in the proportion of 
females who had preventive 
medical examinations. 

A comment regarding the 
validity of these data is in 
order. Since interviewers do 
not provide a definition of 
"checkup," how a person 
responds to this question 
depends on that person's 
definition. But in the absence 
of any knowledge that one 
racial, income, or educational 
group defines a checkup 
more strictly than another, 
the existence and direction of 
a possible bias is difficult to 
ascertain. 

2. Preventive Medical 
Procedures 

In December 1980, results 
from the first National Health 
and Nutrition Examination 
Survey (NHANES I) were 
published in the document, 
"Basic Data on Health Care 
Needs of Adults Ages 25-74 
years, 1971-1975." That 
survey gathered information 
regarding the use of selected 
kinds of medical procedures 
for the early detection of 



208 



disease. The specific types of 
medical procedures were: 
cardiogram, blood pressure, 
chest xray, blood tests, 
urinalysis, vision, hearing, 
rectal exam, and female inter- 
nal exam. 

The proportions of the 
population who received 
these preventive procedures 
during a checkup examina- 
tion are presented by 
selected demographic 
characteristics in Tables 2 
and 3. While racial, sex, and 
income groups differ in the 
numbers who report having 
had some selected preven- 
tive care examination, dif- 
ferences among age groups 
are not as notable. With the 
exception of female internal 
examinations, a higher pro- 
portion of blacks than whites 
received each of the pro- 
cedures reported in Table 2. 
Two tests for which the dif- 
ference was great are chest 
xrays (60.51 percent of 
blacks, 49.76 percent of 
whites) and vision tests 
(40.23 percent of blacks and 
30.09 percent of whites). 
Also, a larger proportion of 
men than women had each 
of the tests or procedures 
performed. The differentials 
between several of these 
preventive examinations were 
great: 45.49 percent of men 
and 17.03 percent of women 
had vision tests; 33.97 per- 
cent of men and 9.43 per- 
cent of women had hearing 
tests; 62.04 percent of men 
and 40.47 percent of women 
had chest xrays. 

While the rate of car- 
diogram usage increased as 
patient age increased, the 
reverse was true for the use 
of hearing tests. 

Family income was a 
significant factor for four of 
the preventive procedures: 
vision tests (26.03 percent of 



the lowest income persons 
compared with 32.83 percent 
of the highest income per- 
sons); hearing tests (17.54 
percent of lowest family in- 
come persons compared with 
22.13 percent of the highest 
family income persons); rectal 
examinations (40.60 percent 
of low income persons com- 
pared with 52.67 percent of 
high income persons); and 
female internal examinations 
(55.12 percent of low family 
income persons compared 
with 74.62 percent of high 
family income persons). 

Of the nine procedures 
listed, two are common to 
most physician visits, 
whatever the purpose of the 
visit. These are blood 
pressure checks and 
urinalysis. Tables 2 and 3 
report these two procedures 
as administered most fre- 
quently to patients receiving 
general checkups (97.45 per- 
cent for blood pressure 
check; 83.31 percent for 
urinalysis). Also note that 
these procedures appear to 
have little relation to race, 
sex, age, or income. The re- 
maining procedures are more 
specialized and are probably 
administered more select- 
ively. Some are common to 
preemployment or intermittent 
employment examinations 
(e.g., vision and hearing 
tests, chest xrays). This may 
explain the higher propor- 
tional use of these pro- 
cedures among males than 
females. Too, males have 
general "checkup" examina- 
tions as a requirement to par- 
ticipate in extracurricular 
activities and to qualify for in- 
surance coverage. As stated 
before, a larger proportion of 
blacks received each of 
these preventive procedures 
than whites, although the pro- 
portional differences were not 
great, with the exception of 
chest xrays. Whether this is 



due to administrative re- 
quirements of employment or 
extracurricular activities, or to 
blacks' predispositions 
toward some diseases (e.g., 
tuberculosis), or, other 
reasons, cannot be determin- 
ed from the data in Tables 1 
and 2. 

3. Prenatal Examinations 

Prenatal care has played a 
major role in the overall 
downward trend in infant 
mortality in the United States. 
Infant deaths are primarily 
immaturity-associated (low 
birthweight), and the greatest 
chance of preventing low bir- 
thweight is through early 
prenatal medical attention. 
Over 95 percent of the 
women with live births in 
1980 sought prenatal care 
before delivery, although the 
time during the gestation 
when they sought the care, 
and the amount of prenatal 
care visits they made, varied 
according to the mother's 
racial/ethnic group and 
educational attainment (see 
Table 4). 

A higher proportion of 
whites (81 .3 percent) than 
blacks (61.1 percent) visited 
a physician for the first time 
during the first trimester. 
"The proportion of Hispanic 
mothers who received 
prenatal care in the critical 
first trimester of pregnancy 
(60.3 percent) was substan- 
tially lower than for white 
non-Hispanic mothers but 
about the same for black 
non-Hispanic mothers." (4, p. 
4) 

Failure to receive prenatal 
care during the first trimester 
can cause irreversible 
damage and lifelong handi- 
caps to the newborn. Never- 
theless, 39.8 percent of 
Hispanic first visits, 38.9 per- 
cent of non-Hispanic black 
first visits, and 18.7 percent 



of non-Hispanic white first 
visits occurred after 4 months 
or more of pregnancy. The 
proportion of Hispanic 
mothers who received no 
prenatal care at all (3.8 per- 
cent) before delivery was 
generally comparable to non- 
Hispanic blacks (3.2 percent) 
but greatly exceeded the pro- 
portion of non-Hispanic white 
mothers (0.8 percent). Prob- 
ably because a greater pro- 
portion of Hispanic women 
began their prenatal care 
later than non-Hispanic 
whites, their median rate of 
visits was almost two visits 
less (for Hispanics 9.5, 11.4 
for non-Hispanic whites). 
Compared to non-Hispanic 
blacks, the median number 
of visits for Hispanics was 
one visit less. 

Among the various 
women of Hispanic origins 
there was considerable varia- 
tion as to the month of begin- 
ning prenatal care and the 
median number of prenatal 
physician visits. Only 1 per- 
cent of Cuban women re- 
ceived no prenatal care, 82.7 
percent sought medical care 
during their first trimester, 
and their median number of 
visits was 1 1 .4. It is apparent 
that Cuban women most 
resembled non-Hispanic 
white women in obtaining 
early prenatal care and in the 
number of visits they made 
for such care. The beginning 
of prenatal care and the 
median number of visits for 
Puerto Rican women was 
substantially different. In 
1980, slightly more than half 
(55.1 percent) of Puerto 
Rican mothers received 
prenatal care in the first 
trimester, and they made 
fewer visits for care (9.2) than 
any other Hispanic or non- 
Hispanic group. 

" . . .Studies have shown 
that young mothers with low 



209 



educational attainment as 
well as women having high 
order births are especially 
unlikely to receive early 
prenatal care." (4, p. 6) 
"Mothers of Hispanic origin 
were considerably less likely 
to have completed high 
school than were non- 
Hispanic mothers. Cuban 
mothers were the only 
Hispanic group whose 
educational attainment was 
generally comparable with 
that of white non-Hispanic 
mothers. In 1980, 49.0 per- 
cent of Hispanic mothers had 
completed at least 12 years 
of schooling compared with 
81.9 percent for white non- 
Hispanic and 62.9 percent 
for black non-Hispanic 
mothers [see Table 5]. These 
data were available for 20 
States in 1980. California and 
Texas did not require the 
reporting of educational at- 
tainment. As a result, educa- 
tional attainment is available 
for just 36.6 percent of all 
Hispanic origin births and for 
only 17.0 percent of Mexican 
births in the 22 States ." (5, 
P 4) 

One of the pregnancy and 
infant health goals identified 
as a priority for Federal effort 
is that by 1990, the propor- 
tion of women in any 
geographic, racial, or ethnic 
group who obtain no prenatal 
care during the first trimester 
should not exceed 10 
percent. 

"In recent years, the 
development and use of high 
technology diagnostic techni- 
ques has increased in all 
medical specialties. This in- 
crease has been especially 
rapid in obstetric and 
newborn care. Many techni- 
ques for information gather- 
ing and risk assessment that 
were unavailable a few years 
ago are now frequently used 
in the management of 
pregnancy and delivery." (6, 
p. 63) 



Three prenatal diagnostic 
techniques used for assess- 
ing fetal well-being are 
discussed here, including a 
brief description of the actual 
procedure, and data 
reporting the use of the tests 
among selected subgroups 
of the population. The 
descriptions of amniocentesis 
and ultrasound quoted below 
were taken from The Nurse's 
Reference Library: Assess- 
ment (7, p. 764). 
Amniocentesis is 
performed by inserting a 
needle into the patient's 
abdomen, through the 
uterus, and into the am- 
niotic sac to aspirate a 
sample of the amniotic 
fluid. Amniocentesis is 
used for assessing fetal 
maturity, especially when 
a cesarean section is 
planned. Amniocentesis is 
also used for prenatal 
diagnosis of genetic 
disorders, especially if 
maternal age is advanced 
(over 35) or a history of 
chromosomal abnor- 
malities exists. 
In 1980, 29 percent of 
mothers over the age of 35 
received amniocentesis dur- 
ing their pregnancies. The 
percentage of white women 
receiving amniocentesis was 
almost twice as high as black 
women, 30.0 to 16.7 (see 
Table 6). A smaller proportion 
of women from nonmetro- 
politan areas as well as 
women from the South 
received amniocentesis com- 
pared to women from 
metropolitan areas and the 
other three geographic 
regions. 

Ultrasound is used for 
assessing fetal well-being 
by placing an ultrasonic 
transducer on the 
mother's abdomen which 
transmits high-frequency 
sound waves. These 
sound waves pass 



through the abdominal 
wall, deflect off the fetus, 
and bounce back to the 
transducer, where they're 
translated into a visual im- 
age on a monitoring 
screen. The ultrasound 
test permits early iden- 
tification of pregnancy, 
fetal position and presen- 
tation, fetal anomalies, and 
observation of fetal car- 
diac activity and breathing 
movements. 
For most obstetric uses, ultra- 
sound has replaced xray 
because it is considered 
harmless to the mother and 
fetus. The racial disparity that 
is obvious in the data for am- 
niocentesis is almost nonexis- 
tent for the ultrasound testing 
(see Table 7). About 30 per- 
cent of all pregnant women 
had at least one ultrasound 
procedure during their 
pregnancy. Of the 30 per- 
cent, 29.1 percent were 
white, 30.6 were black. The 
most significant difference is 
between black mothers 
residing in metropolitan areas 
(34.9 percent) and non- 
metropolitan areas. (19.0 
percent). 

For many years, xrays 
have been used as an 
obstetric diagnostic technique 
for pregnant women. Since 
no safe limit of radiation 
dosage has been established 
for the fetus, the use of x- 
rays for this purpose is ques- 
tionable, especially today, 
when many of the tests for 
which xrays have been used 
can be conducted by ultra- 
sound. In 1980, about 13 
percent of all pregnant 
women had at least one 
medical xray during preg- 
nancy; 13.5 percent of these 
women were white, 10.8 per- 
cent were black (see Table 
8). The use of xray is greater 
in nonmetropolitan areas 
(15.5 percent) than in 
metropolitan areas (11.8 per- 
cent). This is particularly true 
for black women in 
nonmetropolitan areas (17.4 
percent). Presumably the use 



of xray is greater in the non- 
metropolitan areas because 
the use of ultrasound has not 
reached these outlying 
districts to date. This is of 
particular concern, since 
Table 8 shows how many of 
the xray procedures per- 
formed on black non- 
metropolitan women possibly 
could have been replaced 
with an ultrasound procedure 
(10.1 percent). 

Certain aspects of a preg- 
nant woman's lifestyle may 
affect the course of her 
pregnancy. Two of these 
which have been proven 
repeatedly to have harmful 
results are cigarette smoking 
and alcoholic beverage 
intake. 

Small infants are more fre- 
quently born to mothers who 
smoke, and strong evidence 
exists that a mother who 
smokes is more likely to have 
an unsuccessful pregnancy. 
An excessive intake of 
alcoholic beverages during 
pregnancy may produce fetal 
alcohol syndrome in the 
newborn. Children of 
alcoholic mothers may also 
experience growth retardation 
and other related problems. 
No safe level of alcohol in- 
take during pregnancy has 
been identified. 

Figure 1 shows that 
almost half of married women 
abstained from both smoking 
and drinking during their 
pregnancies. This represents 
a 12.5 percent increase over 
those who also abstained 
prior to their pregnancies. A 
further breakdown of the data 
in Table 9, however, in- 
dicates that abstinence from 
one or both of these habits 
was related to race, age, and 
educational level. The educa- 
tional level and age of 
mothers who had chosen to 
quit smoking during their 
pregnancy appear to be 
quite significant. A greater 
proportion of young mothers 



210 



Figure 1 

Percent distribution ot married mothers of live-born infants, according to 
smoking and drinking behaviors before and during pregnancy: United 
States, 1980. 



Before pregnancy 




During pregnancy 




Source: National Center for Health Statistics: Preliminary data from the National 
Natality Survey. In Health, United States, 1983. DHHS Pub. No. (PHS) 84-1232. 
Hyattsville, MD, December 1983. 



(about 20 percent) stopped 
smoking compared to older 
mothers (about 7 percent). 
The age group data are very 
similar for "all races" and for 
whites; there appears to be 
no relation between age and 
race. More of those mothers 
who completed 16 years of 
schooling than those who 
had 0-11 years of schooling 
abstained from smoking dur- 
ing pregnancy. The propor- 
tional difference is great: 24.2 
percent with the highest level 
of education abstained, and 
9.8 percent with the least 
amount of schooling. As with 
the age data, no racial dif- 
ferences are reported for 
these data. 

The change in drinking 
habits of pregnant women is 
not as pronounced as is the 
change in smoking patterns. 



Proportionally fewer white 
women than black women or 
"other race" women stopped 
drinking. Also, as women in- 
creased in age from under 
20 years to 35 years and 
over, they were less likely to 
stop drinking, regardless of 
race. 

One of the objectives that 
the Public Health Service 
hopes to achieve by 1990 is 
that 85 percent of women of 
childbearing age should be 
able to choose foods wisely 
(state special nutritional 
needs of pregnancy) and 
understand the hazards of 
smoking, alcohol, phar- 
maceutical products, and 
other drugs during 
pregnancy and lactation. 



C. Immunization 

The seven major childhood 
infectious diseases are 
poliomyelitis, mumps, tetanus, 
diptheria, rubella, pertussis 
(whooping cough), and 
measles. They can all cause 
permanent disability and, in 
some cases, death. Despite 
the fact that effective im- 
munizations have long been 
available to protect children 
from these diseases, the pro- 
portion of young children 
protected by immunization is 
only between 60 and 70 per- 
cent, with much lower pro- 
portions in urban ghettos and 
poor rural areas of the na- 
tion. Table 10 clearly shows 
that immunization is most 
lacking in central city areas 
and within the poverty areas 
of central cities. 

The control of childhood 
disease requires constant 
vigilance because, except for 
smallpox, the causal agents 
have not been eradicated. 
There were 385,000 cases of 
measles in 1963 when the 
vaccine was first developed, 
22,000 cases by 1968, and 
70,000 cases in 1971 (8, p. 
14). A drop in immunization 
levels in the early 1970's 
resulted in over one-third of 
children under 15 years of 
age being inadequately pro- 
tected by 1976. This was ac- 
companied by a 63 percent 
rise in rubella cases and a 39 
percent rise in measles 
cases. 

The National Childhood 
Immunization Initiative of 
1977 made a large difference 
in the immunization levels of 
school-age children. By the 
fall of 1979, 91 percent of 
children in kindergarten 
through eighth grade had 
been protected against 
measles, polio, and DPT 
(diphtheria, pertussis, 
tetanus); 84 percent were 
protected against rubella. 
Eight-one percent of children 
entering kindergarten were 



protected against mumps (2, 
p. 302). In Objectives for the 
Nation it is stated that by 
1990 at least 95 percent of 
children attending 
kindergarten through 12th 
grade should be fully im- 
munized against the seven 
major childhood diseases. 
Also by 1990, the Public 
Health Service aims to 
eliminate the indigenous oc- 
currence of measles. It would 
like to see fewer than 500 
cases of measles (compared 
to 13,506 cases in 1980). All 
cases would be a result of 
importation and would be 
confined within two genera- 
tions of spread. 

Judging by the success of 
the 1977 National Childhood 
Immunization Initiative, there 
is no reason to doubt that the 
1990 immunization goals of 
the Public Health Service will 
be attained. All segments of 
the population are likely to 
benefit from this initiative- 
whites and nonwhites, 
Hispanics and non-Hispanics, 
urban and rural, poor and 
nonpoor. Not only are the im- 
munization levels of the 
underprivileged apt to go up, 
but also their incidence of 
disease is apt to drop (even 
among individuals who are 
not immunized). 

On the other hand, even if 
these objectives are attained, 
there could still be significant 
differences in the immuniza- 
tion levels of preschool ad- 
vantaged and disadvantaged 
children. This conclusion is 
supported by data gathered 
before and after the 1977 Im- 
munization Initiative (see 
Table 10). By requiring im- 
munization for admittance to 
school, government agencies 
can greatly influence the im- 
munization levels of school- 
age children. But immuniza- 
tion levels of preschool 
children are much harder to 
control. Table 10 shows im- 



211 



munization levels of children 
1 to 4 years of age between 
1974 and 1981. Between 
those years, the percent of 
vaccinated nonwhite 
preschool children went 
down for DPT and polio, but 
went up for the other three 
vaccines. The protection 
levels of central city pre- 
school children went down 
for four of the five vaccines 
between 1974 and 1981. It 
went up for the mumps vac- 
cine, mainly because this 
vaccine was relatively new 
and underused in 1974. One 
of the startling statistics found 
in Table 10 is that non-SMSA 
areas in 1974 were below the 
total levels for all five vac- 
cines; by 1981 this inverted, 
however, and non-SMSA 
areas were above the total 
levels. 

In addition to the objec- 
tives already mentioned, the 
Public Health Service aims 
by 1990 to have 90 percent 
of all children complete their 
immunization series by age 
2. This difficult objective will 
be attacked with grants and 
education programs aimed at 
new mothers, hospitals and 
clinics, daycare centers, low 
income mothers, State and 
local health agencies, physi- 
cians, professional organiza- 
tions, and private industries. 
Projects to instruct new 
mothers about immunization 
schedules are very active in 
most States. If this initiative is 
successful, it promises to nar- 
row the immunization gap 
between advantaged and dis- 
advantaged preschool 
children. 

D. Overall Health 
Assessment 

How one perceives the state 
of his or her health may or 
may not be a valid measure 
of health status. Even if 
perception does not reflect 
health status, it may motivate 



individuals to take curative or 
preventive health actions. 
Evidence for this proposition 
is found in the National 
Medical Care Utilization and 
Expenditures Survey 
(NMCUES) 1980 data. That 
survey reported that persons 
with perceived health 
statuses of excellent, good, 
fair, and poor had an 
average number of physician 
visits of 2.94, 4.15, 7.42, and 
11.36, respectively (9, p. 31). 

In addition to "self assess- 
ment of health" data from the 
NMCUE Survey, this section 
includes data from the Na- 
tional Health Interview 
Survey. Both surveys are 
used because the former in- 
cluded Hispanic data, and 
the latter included 1976 and 
1981 data and thus 
examined change over a 
5-year period. 

Data resulting from this 
type of survey methodology 
have two notable limitations. 
First, they are based on the 
respondent's perception of 
his or her own health, and 
second, they are based on 
the respondent's perception 
of each family member's 
health. 

Most people in the United 
States assess their own 
health as good or excellent. 
In 1980, about half the 
population (46.6 percent) 
assessed their health as ex- 
cellent; 86.3 percent per- 
ceived their health as good 
or excellent. Racial groups 
showed some differences, 
but a large proportion of 
each of the groups claimed 
as good or excellent health: 
Hispanics, 87.3 percent; 
whites, 86.8 percent; and 
blacks, 82.2 percent. 

The U.S. Hispanic popula- 
tion is relatively younger and 
their proportionally high 
reporting of good to excellent 
health may therefore be ex- 
pected, since younger 
people usually are in better 



health and perceive their 
health as such. Blacks as a 
group, however, are also 
younger than the general 
population, but their assess- 
ment of excellent or good 
health falls 5.1 percent below 
Hispanics and 4.6 percent 
below whites (10, p. 39). In- 
terpretation of these self- 
reported data should be 
done with caution, since 
there is a good chance that 
age-adjusted, self-reported 
data may show greater 
racial/ethnic differentials. 

Perceived health status 
from the National Health In- 
terview Survey in 1976 and 
1981 shows that proportions 
remained basically 
unchanged over the 5-year 
period (see Table 11). In 
1981, 11.8 percent of the 
total population reported their 
health as fair or poor, com- 
pared to 12.1 percent in 
1976. The survey found that 
10.8 percent of whites had 
an assessment of fair or poor 
in 1981 (11.1 percent in 
1976), while 19.7 percent of 
blacks had such an assess- 
ment (19.9 in 1976). As in- 
come increased over 
$10,000, the proportion of 
persons who assessed their 
health as good or excellent 
also increased; each family 
income grouping above 
$10,000 showed a drop in 
the percentage reporting fair 
or poor health status. It ap- 
pears, however, that the 
greatest improvement was in 
the $10,000-to-$1 4,999 in- 
come group. 

E. Lifestyles 

"Many aspects of our current 
lifestyle are not conducive to 
health. We smoke cigarettes, 
we drink alcohol, we get too 
little exercise, we eat too 
much, we live tense lives, we 
do not fasten seat belts, and 
we often do not take ade- 
quate care in other ac- 
tivities." (11, p. 690) 

The preceding quotation 
clearly states the subject area 



of this section: nonmedical 
lifestyle patterns that affect 
health. This inclusion is 
based on the current thinking 
among health professionals, 
that given today's disease 
patterns, behavioral modifica- 
tion and health education 
may be more influential in im- 
proving health status than ad- 
ditional medical care. 

The following statement 
was made at a National Con- 
ference on Preventive 
Medicine: 

An important means of 
preventing the health 
problems of our day, then, 
is to influence the daily 
habits of people. These 
health problems are now 
known to be caused 
largely by various aspects 
of a new style of life, in- 
cluding cigarette smoking 
and excessive consump- 
tion of alcohol and food, 
that prevails among many 
people in the United 
States. The means of deal- 
ing with the current major 
health problems, thus, will 
evidently be much more 
dependent on personal, 
lifelong behavior than has 
been true of health prob- 
lems in the past. It will be 
necessary to involve in- 
dividuals themselves in 
controlling these diseases, 
at least in the face of our 
present understanding of 
the origin of the major 
chronic diseases. (12, p. 
113) 

The three major lifestyle 
problems of cigarette smok- 
ing, alcohol consumption, 
and obesity are treated in 
this section, and the dif- 
ferences in the lifestyle trends 
among the disadvantaged 
are discussed. 
1 . Cigarette Smoking 
"Cigarette smoking is the 
largest single preventable 
cause of illness and 
premature death in the 
United States. Cigarette 
smokers have a 70 percent 
higher overall death rate than 
nonsmokers, and tobacco is 



212 



associated with an estimate 
in excess of 300,000 
premature deaths per year. 
The major single cause of 
cancer mortality in the United 
States is cigarette smoking, 
contributing to more than 
100,000 cancer deaths an- 
nually. Smoking is a causal 
factor in coronary heart 
disease and arteriosclerotic 
peripheral vascular disease 
and is also the most impor- 
tant cause of chronic obstruc- 
tive lung disease. Cigarette 
smoking acts synergistically 
with alcohol to increase the 
likelihood of cancer of the 
larynx, esophagus, and oral 
cavity, with other coronary 
risk factors such as hyper- 
cholesteremia to aggravate 
cardiovascular risk, and with 
oral contraceptives to in- 
crease the risk of coronary 
heart disease and some 
forms of cerebrovascular 
disease. During pregnancy, 
cigarette smoking can in- 
crease the risk of spon- 
taneous abortion, retarded 
fetal growth, and even fetal 
or neonatal death." (13, 
p. 260) 

Since the release of the 
first Surgeon General's report 
in 1964, more than 30 million 
smokers have quit smoking 
cigarettes, and the proportion 
of adult smokers has 
declined from about 42 per- 
cent in 1965 to approximately 
33 percent in 1980 (13, 
p. 260). The proportion of 
men who smoke declined to 
37.9 percent in 1980 and the 
proportion of women who 
smoked dropped to 29.8 per- 
cent. Although the propor- 
tions of adults who are 
smokers is decreasing for 
both sexes, the rate of 
decrease has been more 
precipitous among females 
than males. This has caused 
the male-to-female ratio to 



drop from 1 .52 in 1965 to 
1.27 in 1980 (see Table 11). 

The most recent data to 
show racial comparisons of 
smoking behavior are 
presented in Tables 12 and 
13. They present some in- 
teresting findings. Through 
the reported years, a higher 
proportion of blacks have 
smoked cigarettes than 
whites. Those whites who 
smoked, however, tended to 
smoke much more heavily 
than blacks. It is also clear 
from the 1980 data that a 
higher proportion of whites 
are giving up smoking (are 
former smokers) than are 
blacks. 

The Health Interview 
Survey periodically includes 
cigarette smoking questions 
to obtain updated information 
about the prevalence of 
smoking, and the charac- 
teristics and behavior of 
smokers. The 1978 question- 
naire contained items to iden- 
tify smokers who have at- 
tempted to quit at some time. 
The data show that the ma- 
jority of smokers have made 
at least one serious attempt 
to quit during their smoking 
years. About the same 
percentage of black and 
white smokers attempted to 
quit at some time. More 
blacks than whites, however, 
reported having attempted to 
quit smoking during the year 
of the survey (blacks, 36.6 
percent; whites, 25.1 per- 
cent). Although a slightly 
higher proportion of men 
than women ever attempted 
to quit, the 1978 data 
showed more women trying 
to quit (28.3 percent of 
women versus 24.4 percent 
of men). This sex difference 
was more apparent among 
blacks than among whites 
(14, p. 8). 

To improve health through 
smoking control, Objectives 
for the Nation has stated that 
by 1990 the proportion of 
adults who smoke should be 
reduced to below 25 percent. 



2. Alcohol Consumption 

"Currently (1979 data), 
average consumption of 
alcohol for all persons over 
14 years of age is 10 percent 
higher than 10 years ago 
and is equivalent to about 
2.75 gallons of ethanol per 
person per year. The relation- 
ship of drinking and driving, 
especially among teenagers, 
has become of increased 
public concern. Substantial 
health costs to society result 
from alcohol misuse. About 
10 percent of all deaths in 
the United States are alcohol 
related. Cirrhosis of the liver 
is largely attributable to 
alcohol consumption. The 
cause-of-death category 
"chronic liver disease and 
cirrhosis" ranks among the 
10 leading causes of death. 
Alcohol use also is 
associated with cancer of the 
liver, pancreas, esophagus, 
and mouth. The misuse of 
alcohol leads to increased 
risk of injury and death to 
self, family members, and 
others, especially by fires and 
motor vehicle and other ac- 
cidents." (13, p. 261) 

Regarding the drinking 
habits of the disadvantaged, 
the results of surveys show 
that the frequency of alcohol 
consumption rises directly 
with family income. Table 14 
shows in 1977, that 46 per- 
cent of those with family in- 
comes less than $5,000 were 
abstainers, but only 15 per- 
cent of those with family in- 
comes of $25,000 and over 
abstained. Table 14 also 
shows that alcohol consump- 
tion increases with age and is 
more prevalent among 
males. Consumption has also 
been rising over time (see 
Table 15). Table 15 shows a 
consistent rise in the percen- 
tage of the population that 
used alcohol between 1972 
and 1979. Although more 
whites consume alcohol than 
nonwhites, the rise in the pro- 



portion using alcohol be- 
tween 1976 and 1979 was 
about equal for blacks and 
whites. The age group data, 
however, indicate the 
possibility that blacks (and 
"others") will eventually be 
consuming alcohol at the 
same or greater rates than 
whites. Between 1976 and 
1979, the following changes 
occurred in white/black (and 
"other") ratios: among youths 
the ratio dropped from 1 .48 
to 1.31; among young adults, 
1.33 to 1.25; among adults 
1.14 to 1.10. These drops 
suggest that if these alcohol 
consumption practices con- 
tinue, the black rates will ap- 
proximate those of whites ap- 
proximately a generation 
from now. 

The goal for 1990 states 
that per capita consumption 
of alcohol should not exceed 
current levels (in 1978, about 
2.82 gallons of absolute 
alcohol were consumed per 
year per person aged 14 
years and over). 
3. Obesity (Overweight) 
Obesity, a surplus of body 
fat, is usually defined by the 
sum of triceps and 
subscapular skinfold 
thickness. "Overweight" 
refers to the deviation within 
the "fatness range" from 
desirable weight, as shown in 
height-weight tables. The two 
measures are correlated but 
independent. Only 13 per- 
cent of adult men and 22 
percent of adult women are 
both obese and overweight, 
at or above the 85th percent- 
ile (15, p. 5). 

Obesity, or overweight 
resulting from excess body 
fat, has been linked as a risk 
factor in the development of 
hypertension, gallbladder 
disease, and diabetes. In ad- 
dition to the increased risk of 
developing certain diseases, 
there are the social, 
psychological, and economic 
costs of obesity. Obese 



213 



Figure 2 

Comparative fatness trends of black and white female participants in the 
Ten State Nutrition Survey 



Triceps Fatfold (mm) 
1 2 3 

26 



24 
22 
20 
18 
16 
14 
12 
10 



FEMALES 



Blacks 



4 5 6 8 10 



20 30 40 60 80 



I ... . 



Whites 




Prepubertal 
Gain 



people appear to be 
discriminated against in both 
educational and employment 
opportunities, particularly with 
respect to the opportunity for 
better paying jobs (16, 
p. 32). 

Table 16 reports data on 
obese adults from the 
1971-1974 Health and Nutri- 
tion Examination Survey 
(HANES). That study found 
that the largest proportion of 
obese adults were black 
females aged 20 to 44, while 
the lowest proportion of 
obese adults were black 
males aged 45 to 74. More 
black females were obese 
than white females, and the 
rates for white and black 
males were similar (see 
Table 16). 

These findings are consis- 
tent with those reported in 
The Ten State Nutrition 
Survey, which examined 
obesity and overweight in a 
sample U.S. population. 
Figure 2 demonstrates the 
fatness trends of black and 
white females through several 
life stages. Further, it 
demonstrates the observa- 
tions of S.M. Garn, a noted 
nutritionist with several 
publications on obesity. Garn 
recognizes the problem of 
obesity in post-adolescent 
black females and refers to it 
as an age-related reversal of 
fatness. From a very young 
age, white females are 
systematically fatter than 
black females of the same 
age until adolescence, when 
there is a reversal of this 
trend that persists throughout 
adult life (17, p. 97). 

Two nutrition-related goals 
from Objectives of the Nation 
that are relevant to the topic 
of obesity are: 1) By 1990, 
the prevalence of significant 
overweight (120 percent of 
"desired" weight) among the 
U.S. adult population should 



be decreased to 10 percent 
of men and 17 percent of 
women, without nutritional im- 
pairment. (In 1971-74, 14 
percent of adult men and 24 
percent of women were more 
than 120 percent of 
"desired" weight). 2) By 
1990, 50 percent of the 
overweight population should 
have adopted weight loss 
regimens, combining an ap- 
propriate balance of diet and 
physical activity. 

In the Health Interview 
Survey conducted by NCHS, 
people over 1 7 years of age 
were asked if they con- 
sidered themselves to be 
overweight. Although a 
higher percentage of black 
women are overweight, more 
white women (50 percent) 
than black women (44 per- 
cent) considered themselves 
to be overweight. As income 
increased, more women 
perceived themselves to be 
overweight, even though 
women below the poverty 
line tend to be heavier than 
women above the poverty 
line (16, p. 33). 

Regarding the three 
behavior patterns (smoking, 



drinking, overeating) that 
have the greatest impact on 
prevalent disease conditions 
of today, the white male 
presently appears to be most 
involved with a lifestyle that 
may have serious health 
ramifications. The trend data 
for most groups of our 
society, however, indicate 
that each of the population's 
major subgroups is rapidly 
approaching the excessive 
lifestyle level of the white 
male. In absolute numbers, 
more females, both black 
and white, are smoking than 
ever before. Black youths are 
consuming large amounts of 
alcohol and, should they con- 
tinue this practice into 
adulthood, their consumption 
rate will equal or exceed the 
present level of consumption 
of the white male. Presently, 
a large number of black 
females are seriously obese; 
however, obesity and 
overweight is significantly 
more prevalent among 
women of all races/ethnic 
groups than among men of 
comparable ages. 



214 



Table 1 

Percent of population with a general checkup within a year, by 
selected characteristics: United States, 1980. 

Characteristic Percent with general checkup 



All persons' 39.3 

Sex 

Male 33.8 

Female 44.4 

Race 

White 41.3 

Black 42.2 

Family income 

Less than $5,000 26.8 

$5,000 $9,999 39.4 

$10,000 $14 999 37.2 

$15,000-$24,999 40.7 

$25,000 or more 39.4 

Education of head of family 

Less than 9 years 29.4 

9-11 years 34.9 

12 years 38.8 

13-15 years 45.5 

16 years or more 48.9 



'Includes races other than white or black, unknown family income and unknown educa- 
tion ot head of family 

Source: Compiled and abstracted by CHESS from National Center for Health Statistics. 
J G. Collins: Physician visits, volume and interval since last visit, United States, 1 980 
Series 10, No. 144, DHHS Pub. No. (PHS) 83-1572. Public Health Service Washington. 
DC, U S Government Printing Office, June 1983 



Table 2 

Percent of persons ages 25-74 years by race, sex, age, and selected tests or procedures received during checkup: United States, 
1971-75. 



Selected tests or procedures 


Total 1 


Race 




S< ■ > 






Age in years 






White 


Black 


Men 


Women 


25-34 


35-44 


45-54 


55-64 


65-74 












Percent of persons 










Cardiogram 


34.06 


33.62 


37.30 


40.97 


27.44 


15.39 


29.72 


39.71 


48.84 


53.90 


Blood pressure check 


97.45 


97.31 


98.62 


98.77 


96.18 


96.92 


97.24 


97.14 


98.31 


98.37 


Chest X-ray 


51.02 


49.76 


60.51 


62.04 


40.47 


44.14 


48.72 


53.40 


57.45 


57.49 


Blood tests 


77.08 


76.49 


81.92 


81.71 


72.64 


73.68 


76.61 


77.77 


80.44 


79.65 


Urinalysis 


83.31 


83.28 


83.29 


87.10 


79.68 


83.01 


85.34 


82.03 


84.41 


80.90 


Vision tests 


30.94 


30.09 


40.23 


45.49 


17.03 


36.37 


33.81 


29.96 


25.88 


21.96 


Hearing tests 


21.43 


20.97 


25.58 


33.97 


9.43 


24.69 


22.50 


20.70 


19.83 


15.21 


Rectal examination 


48.57 


48.43 


50.07 


52.46 


44.85 


45.04 


48.24 


52.11 


49.01 


50.19 


Internal examination (women). . . 


67.54 


68.43 


60.25 




67.54 


75.71 


75.88 


64.09 


58.32 


54.67 



'Includes races other than white and black. 

Source: National Center for Health Statistics, W.C. Hadden: Basic data on health care needs of adults ages 25-74 years, 
United States, 1971-1975 Series 11, No. 218. DHHS Pub No. (PHS) 81-1668 Public Health Service. Hyattsville, MD, 
December 1980. 



215 



1 me 3 

Percent of persons ages 25-74 years by annual family income and selected tests or procedures received during checkup: United 



States, 1971 /'> _ 

Annual family income group 

Selected tests or procedures Total 

Less than $4,000 $4,000-86,999 $7,000-39,999 $10,000-$1 4,999 $15,000 or more 

Percent of persons 

Cardiogram 33.91 38.58 33.63 32.58 29.95 36.42 

Blood pressure check 97.43 97.69 96.22 97.40 97.61 97.78 

Chest X-ray 50.68 53.91 51.75 51.17 48.76 50.08 

Blood tests 76.80 74.53 76.62 78.01 75.30 78.32 

Urinalysis 83.07 80.56 80.15 83.35 83.54 85.01 

Vision tests 30.88 26.03 28.66 30.61 32.51 32.83 

Hearing tests 21.23 17.54 23.38 20.65 21.27 22.13 

Rectal examination 48.51 40.60 48.66 46.62 49.12 52.67 

Internal examination (women) 67.74 55.12 62.47 68.53 71.58 74.62 



Source: National Center for Health Statistics, W C Hadden: Basic data on health care needs of adults ages 25-74 years, 
United States. 1971-1975 Series 1 1 , No 218 DHHS Pub No (PHS) 81-1668. Public Health Service. Hyattsville, MD. 
December 1980. 



Table 4 

Percent distribution of live births by month of pregnancy prenatal care began and median number of prenatal visits, by Hispanic 
origin of mother, and by race of child for mothers of non-Hispanic origin: total of 22 reporting States, 1980. 

Origin of mother 



Hispanic Non-Hispanic 



Measure of pre- 
natal care 


All 

origins 1 


Total 


Mexican 


Puerto 
Rican 


Cuban 


Central 
and 
South 
Ameri- 
can 


Other 
and 

unknown 
Hispanic 


Total 2 


White 


Black 


Month of pregnancy 










Percent distribution 










prenatal care began 






















Total 


100.0 


100.0 


100.00 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


1st and 2d month . 


50.2 


36.9 


36.1 


32.3 


62.9 


35.5 


42.5 


52.3 


56.2 


37.6 


3d month 


24.5 


23.4 


23.6 


22.8 


19.8 


23.2 


23.9 


24.7 


25.1 


23.5 


4th-6th month 


19.4 


27.8 


28.5 


28.7 


13.4 


28.1 


24.4 


18.1 


15.2 


29.3 


7th-9th month 


4.2 


8.2 


8.5 


7.9 


2.8 


8.2 


7.5 


3.6 


2.7 


6.4 


No prenatal care . . 


1.6 


3.8 


3.4 


8.3 


1.0 


5.0 


1.7 


1.3 


0.8 


3.2 


Prenatal visits 3 










Median 










Number 4 


1 1.0 


9.5 


9.3 


9.2 


11.4 


9 6 


10.0 


11.1 


11.4 


10.5 



1 1ncludes origin not stated 

includes races other than white and black 

3 Excludes data for California and New Mexico, which did not report number of prenatal visits. 
4 Excludes births to mothers with no prenatal care 

Source: National Center for Health Statistics: S.J. Ventura: Births of Hispanic parentage, 1980. Monthly Vital Statistics Report 
Vol 32, No 6 Supp DHHS Pub No (PHS) 83-1120. Public Health Service, Hyattsville, MD, September 1983. 



216 



Table 5 

Number of live births and percent distribution of live births by educational attainment of mother and median years of school completed 
by Hispanic origin of mother, and by race of child for mothers of non-Hispanic origin: total of 20 reporting States, 1980. 



Origin of mother 



Years of school 
completed by mother 








Hispanic 






Non-Hispanic 




All 

origins 1 


i otai 


Mexican 


Pi iprtn 


Cuban 


Central 
and South 
American 


Other and 
unknown 
Hispanic 


Totals 


White 


Black 














Number 










l jwp hirth*^ 


1 398 998 


1 12,573 


36,548 


32,041 


6,449 


14,519 


23,016 


1 ?0fi 1Q9 


92? 0?4 


239,579 












Percent distribution 








Total 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


100.0 


0-8 years 


4.7 


23.0 


37.1 


16.8 


8.4 


22.9 


13.2 


3.2 


2.5 


4.8 


9-1 1 years 


1 9.D 


OQ -1 

2o.1 


OCT 


38.5 


15.8 


18.3 


26.9 


18.9 


15.6 


o2. 6 


12 years 


43.6 


34.1 


27.0 


32.5 


41.8 


40.3 


41.5 


44.3 


45.4 


41.7 


13-15 years 


18.2 


10.8 


8.0 


9.3 


22.4 


12.4 


12.9 


18.9 


19.9 


15.3 


16 years or more 


13.9 


4.2 


2.2 


3.0 


11.6 


6.1 


5.5 


14.7 


16.6 


5.9 


Percent completing 12 years 






















or more of school 


75.7 


49.0 


37.2 


44.7 


75.9 


58.8 
Median 


59.9 


77.9 


81.9 


62.9 


Years of school completed . . 


12.6 


11.9 


10.5 


11.6 


12.6 


12.2 


12.2 


12.6 


12.7 


12.3 



'Includes origin not stated. 

includes races other than white and black. 

Note: Excludes data for California and Texas, which did not report educational attainment. 

Source: National Center for Health Statistics, S.J. Ventura: Births of Hispanic parentage, 1980. Monthly Vital Statistics Report. Vol. 
32, No. 6 Supp. DHHS Pub. No. (PHS) 83-1120. Public Health Service, Hyattsville, MD, September 1983. 



Table 6 

Mothers receiving amniocentesis during pregnancy, according to age, race, and location of residence: 

United States, 1980. 

Under 35 years 35 years and over 

Location of residence 7^7^ WNte" Bl^ck AliTa^s" White Bl^k 



Percent of mothers 

All locations 3.9 3.9 5.0 29.0 30.0 16.7 

Metropolitan 4.0 3.7 5.4 33.0 34.8 

South 4.1 4.5 3.3 23.5 20.6 

Other regions 3.9 3.5 6.8 35.7 38.5 

Nonmetropolitan 3.8 3.8 4.0 22.0 22.0 

South 3.5 3.6 3.6 18.5 19.5 

Other regions 4.1 3_9 * 25_0 24^ 



Note: Based on 4,983 births with responses to the item on amniocentesis on the hospital or physician questionnaire. 
* Figure does not meet standards of reliability or precision. 

Source: National Center for Health Statistics: Preliminary data from the National Natality Survey. In Health. United States. 1983. 
DHHS Pub. No. (PHS) 84-1232. Hyattsville, MD. December 1983. 



217 



Table 7 

Mothers with at least one ultrasound procedure during pregnancy, according to race and location of 
residence: United States, 1980. 



Race 

Location of residence All races Z. 7 

White Black 

Percent of mothers 

All locations 29.3 29.1 30.6 

Metropolitan 32.0 31.6 34.9 

South 31.1 31.7 29.8 

Other regions 32.4 31.6 38.6 

Nonmetropolitan 24.2 24.5 19.0 

South 22.3 23.1 18.5 

Other regions 25.6 25.4 



Note: Based on 5,343 births with complete responses from medical sources. 
* Figure does not meet standards of reliability or precision 

Source. National Center for Health Statistics. Preliminary data from the National Natality Survey In Health, United States, 1983 
DHHS Pub No (PHS) 84-1232 Hyattsville. MD. December 1983 



Table 8 

Mothers with at least one medical X-ray during pregnancy, according to reason for X-ray, race, and 
location of residence: United States, 1980. 



Location of residence 




All reasons 




Potential ultrasound 




All races 


White 


Black 


All races 


White 


Black 








Percent of mothers 






All locations 


13.1 


13.5 


1 0.8 


4.9 


4.9 


4.5 


Metropolitan 


11.8 


12.4 


8.3 


3.9 


4.1 


2.4 


South 


12.2 


12.9 


8.0 


4.3 


4.1 


3.4 


Other regions 


11.7 


12.3 


8.5 


3.8 


4.1 


1.7 


Nonmetropolitan .... 


15.5 


15.3 


17.4 


6.8 


6.3 


10.1 


South 


16.8 


16.6 


16.9 


8.5 


7.8 


10.2 


Other regions 


14 6 


14 6 




5.5 


5.4 





Note: Based on 5,343 births with complete responses from medical sources. 
"Figure does not meet standards of reliability or precision 

Source National Center for Health Statistics: Preliminary data from the National Natality Survey In Health, United States, 1983 
DHHS Pub No (PHS) 84-1232 Hyattsville, MD, December 1983. 



218 



Table 9 



Change in smoking 1 and drinking 2 behavior during pregnancy of married mothers of live-born infants, 


dCCUIUIIiy IU ofcMfcJOloU Ol Idl dUltn lollOo. 


United States, 1980. 






Characteristic 


With 


1 or both habits 


With hnth hahtte 
Willi UUIU lldUllb 


Stopped 


Stopped 


Became 


and stopped 




smoking 


drinking 


abstinent 


1 or both 






Percent of mothers 




All married mothers 


17.6 


29.6 


19.6 


4 3 1 


Race 










White 


1 7 7 




1 Q 1 

I C7. I 


42.9 


Black 


12.9 


07 P. 


OK O 


35.3 


Other 3 


20.8 


07 n 
o / .u 


OO A 


55.9 


Hispanic origin 










Hispanic 


25.4 


07 7 


on O 


50.0 


Non-Hispanic 


1 7.3 


OQ 7 


1 y.b 


42.8 


Age 4 










All races: 










Under 20 years . 


1 9.9 


on a 


1 7.4 


54.5 


20-24 years 


1 7.4 


OO o 


-I Q 1 

\ y . \ 


46.5 


25-29 years 


18.0 


OQ c; 


O i O 


41 .2 


30-34 years 


18.9 


OO A 


HQ r 


33.3 


35 years and over 


6.9 


OO -1 

28.1 


1 7.5 


36.1 


\A/hitcv 

vvniie. 










Under 20 years 


20.3 


on £T 

oy .D 


i 7 O 


55.1 


20-24 years 


17.0 


OO A 
O^A 


1 Q A 
1 CS.4 


45.9 


25-29 years 


18.1 


OQ c; 


o -i o 


41.6 


30-34 years 


19.6 


01 0 
c. I .O 


17 7 
I / . / 


33.3 


35 years and over 


7.8 


25.2 


15.9 


34.4 


Education 45 










All races: 










0-1 1 years 


9.8 


29.5 


9.5 


40.5 


12 years 


16.9 


30.8 


19.3 


42.0 


13-15 years . . 


21.8 


25.2 


20.0 


40.0 


16 years or more 


24.2 


29.7 


25.5 


45.9 


White: 










0-11 years 


10.0 


30.2 


9.5 


39.8 


12 years 


16.5 


30.2 


18.6 


41.7 


13-15 years 


23.0 


24.5 


19.7 


40.8 


16 years or more 


24.3 


28.5 


24 5 


44.7 



1 Smokers are those who smoked at least 1 tobacco cigarette per day 

2 Drinkers are those who consumed at least 1 drink (0.5 oz. of absolute alcohol) once a month, 
includes all other races not shown separately. 

4 For all other races, number of cases was too few to meet standards for precision or reliability 
includes mothers who are 20 years of age and over. 

Source: National Center for Health Statistics: Preliminary data from the National Natality Survey. In Health, United States, 1983 
DHHS Pub. No. (PHS) 84-1232. Public Health Service, Hyattsville, MD, 1983. 



Table 10 

Vaccination status of children 1-4 years of age, according to race and standard metropolitan statistical area (SMSA) component: United 
States, 1974, 1976, 1979, and 1981. 

(Data are based on household interviews of a sample of the civilian, noninstitutionalized population.) 

Year, race, and Vaccination 

SMSA component Measles Rubella DTP 1 - 2 Polio? Mumps 



Percent of population 

1974 

Total 64.5 59.8 73.9 

Race 

White 66.8 61.0 76.8 

All other 53.1 53.6 59.6 

SMSA component 

Central city 62.5 61.1 69.5 

Poverty area 3 52.9 55.3 57.3 

Nonpoverty area 66.0 63.2 74.0 

Remaining areas in SMSA 68.5 62.3 77.9 

Non-SMSA 61.6 55.5 73.2 

1976 

Total 65.9 61.7 71.4 

Race 

White 68.3 63.8 75.3 

All other 54.8 51.5 53.2 

SMSA component 

Central city 62.5 59.5 64.1 

Remaining areas in SMSA 67.2 63.5 75.7 

Non-SMSA 67.3 61.5 72.9 

1979 

Total 63.5 62.7 65.4 

Race 

White 66.2 64.7 69.0 

All other 51.2 53.7 49.2 

SMSA component 

Central city 57.8 58.0 58.0 

Poverty area 3 47.7 52.8 48.6 

Nonpoverty area 60.9 59.6 61.0 

Remaining areas in SMSA 65.6 65.1 69.1 

Non-SMSA 66.1 64.1 67.7 

1981 

Total 63.8 64.5 67.5 

Race 

White 65.7 66.6 71.0 

All other 55.3 55.2 52.0 

SMSA component 

Central city 60.0 59.9 58.7 

Remaining areas in SMSA 64.3 64.6 68.8 

Non-SMSA 65.9 6/5 722 

1 Diptheria-tetanus-pertussis 
2 Three doses or more 

3 Geographic areas where 20 percent or more of the population falls below the poverty level as defined by the Bureau of the Census 
in 1970. 

Note Beginning in 1976, the category "don't know" was added to response categories Prior to 1976, the lack of this option forced 
positive answers particularly for vaccinations requiring multiple dose schedules, i.e., polio and DTP 

Source: Centers for Disease Control: United States Immunization Survey, 1981 Public Health Service, DHHS, Atlanta, GA. To be 
published In 1) National Center for Health Statistics: Health. United States, 1982. DHHS Pub. No. (PHS) 83-1232. Public Health 
Service, Hyattsville, MD, December 1982. 2). National Center for Health Statistics Health, United States, 1983. DHHS Pub No. 
(PHS) 84-1232 Public Health Service, Hyattsville, MD, December 1983. 



63.1 



66.7 
45.0 



60.0 
51.5 
63.1 
68.1 
60.0 

61.6 



66.2 
39.9 



53.8 
65.3 
63.9 

59.1 



63.6 
38.9 



52.1 
44.5 
54.4 
61.6 
62.6 

60.0 



63.8 
42.7 



52.6 
62.0 
63.0 



39.4 

41.1 
31.2 

37.9 
28.9 
41.2 
43.9 
35.4 

48.3 



50.3 
38.7 



45.6 
50.7 
47.9 

55.4 



57.5 
46.0 



49.5 
40.8 
52.1 
57.2 
58.5 

58.4 



60.5 
49.1 



52.8 
58.6 
61.9 



Table 11 

Self assessment of health according to selected characteristics: 
United States, 1976 and 1981. 

(Data are based on household interviews of a sample of the civilian, nonmstitution- 
allzed population.) 

Self-assessment 
Selected characteristic of health as 

fair or poor 



1976 1981 



Total 1 ' 2 ' 3 


12.1 


11.8 


Age 






Under 17 years 


4.3 


4.0 


Under 6 years 


4.5 


4.2 


6-16 years 


4.2 


3.8 


17-44 years 


8.3 


8.3 


45-64 years 


22.2 


22.0 


65 years and over 


31.3 


30.1 


Sex 1 






Male 


1 1.4 


11.4 


Female 


12.8 


12.1 


Race 1 4 




White 


1 1 1 


10.8 


Black 


19.9 


19.7 


Family income 1 ' 5 




Less than $7,000 


22.2 


22.5 


$7,000-59,999 


17.2 


18.3 


$10,000-$1 4,999 


13.8 


12.4 


$15,000-$24,999 


10.5 


9.6 


$25,000 or more 


7.3 


6.5 


Geographic region 1 






Northeast 


10.4 


10.3 


North Central 


11.0 


10.9 


South 


14.9 


14.3 


West 


11.0 


10.5 


Location of residence 1 




Within SMSA 


11.1 


11.0 


Outside SMSA 


14.2 


13.5 



1 Age adjusted by the direct method to the 1970 civilian, noninstitutionalized popula- 
tion, using 4 age intervals, 
includes all other races not shown separately, 
includes unknown family income. 

4 ln 1976, the racial classification of persons in the National Health Interview Survey 
was determined by interviewer observation. In 1981, race was determined by asking 
the household respondent. 

5 Family income categories for 1981. Adjusting for inflation, corresponding income 
categories in 1976 were: less than $5,000; $5,000-$6.999; $7,000-59.999; 
$10,000-$1 4,999; and $15,000 or more. 

Source; Division of Health Interview Statistics. National Center for Health Statistics: Data 
from the National Health Interview Survey. In Health, United States. 1983. DHHS Pub. 
No. (PHS) 84-1232, Hyattsville, MD, December 1983. 



221 



Table 12 

Cigarette smoking status of persons 20 years of age and over, according to sex, race, and age: United States, 1965, 1976, and 1980. 

(Data are based on household interviews of a sample of the civilian noninstitutionalized population.) 

Smoking status 

Sex, race, and age Current smoker 1 Former smoker 

1965 1 976 1 980 2 1 965 1 976 1 980 2 



Male 
TotaP" 4 

All ages, 20 years and over 5 

20-24 years 

25-34 years 

35-44 years 

45-64 years 

65 years and over 

White 

All ages, 20 years and over 5 

20-24 years 

25-34 years 

35-44 years 

45-64 years 

65 years and over 

Black 

All ages, 20 years and over 5 

20-24 years 

25-34 years 

35-44 years 

45-64 years 

65 years and over 

Female 



52.1 

59.2 
60.7 
58.2 
51.9 
28.5 



51.3 

58.1 
60.1 
57.3 
51.3 
27.7 



59.6 

67 4 
68.4 

67.3 
57.9 
36.4 



41.6 

45.9 
48.5 
47.6 
41.3 
23.0 



41.0 

45.3 
47.7 
46.8 
40.6 
22.8 



50.1 

52.8 
59.4 
58.8 
49.7 
26.4 



Percent of persons 
37.9 20.3 



39.7 
43.1 
42.6 
40.8 
17.9 



37.1 

39.0 
42.0 
42.4 
40.0 
16.6 



44.9 

45.5 
52.0 
44.2 
48.8 
27.9 



9.0 
14.7 
20.6 
24.1 
28.1 



21.2 

9.6 
15.5 
21.5 
25.1 
28.7 



12.6 

3.8 
6.7 
12.3 
15.3 
21.5 



29.6 

12.2 
18.3 
27.3 
37.1 
44.4 



30.7 

13.3 
18.9 
28.9 
38.1 
45.6 



20.2 

4.1 
11.8 
13.8 
28.6 
33.0 



30.5 

12.1 
20.6 
27.6 
36.9 
47.4 



31.9 

12.2 
21.9 
28.8 
38.4 
50.1 



20.6 

10.6 
11.9 
21.2 
26.3 
26.6 



Total 3 ' 4 

All ages, 20 years and over 5 34.2 32.5 29.8 8.2 13.9 15.7 

20-24 years 41.9 34.2 32.7 7.3 10.4 11.0 

25-34 years 43.7 37.5 31.6 9.9 12.9 14.4 

35-44 years 43.7 38.2 34.9 9.6 15.8 18.9 

45-64 years 32.0 34.8 30.8 8.6 15.9 17.1 

65 years and over 9.6 12.8 16.8 4.5 11.7 14.2 

White 

All ages, 20 years and over 5 34.5 32.4 30.0 8.5 14.6 16.3 

20-24 years 41.9 34.4 33,3 8.0 11.4 12.5 

25-34 years 43.4 37.1 31.6 10.3 13.7 14.7 

35-44 years 43.9 38.1 35.6 9.9 17.0 20.2 

45-64 years 32.7 34.7 30.6 8.8 16.4 17.4 

65 years and over 9.8 13.2 17.4 4.5 11.5 14.3 

Black Percent of persons 

All ages, 20 years and over 5 32.7 34.7 30.6 5.9 10.2 11.8 

20-24 years 44.2 34.9 32.3 2.5 5.0 2.2 

25-34 years 47.8 42.5 34.2 6.7 8.9 11.6 

35-44 years 42.8 41.3 36.5 7.0 9.6 12.5 

45-64 years 25.7 38.1 34.3 6.6 11.9 14.1 

65 years and over 7J 9_2 9 4 4 b 13 3 14.1 

1 A current smoker is a person who has smoked at least 100 cigarettes and who now smokes; includes occasional smokers. 
2 Final estimates. Based on data for the last 6 months of 1980. 
3 Base of percent excludes persons with unknown smoking status. 
■•Includes all other races not shown separately. 

5 Age adjusted by the direct method to the 1970 civilian noninstitutionalized population using 5 age groups. 

Note: Data in this table should not be compared with data in Health, United States, 1981 or Health, United States, 1982. The 1980 data in the 1981 edition were preliminary 
estimates, and the data in the 1982 edition were final estimates but did not include age-adjusted data. 

Source: Division of Health Interview Statistics, National Center for Health Statistics: Data from the National Health Interview Survey. In National Center for Health Statistics: Health, 
United States, 1983. DHHS Pub. No. (PHS) 84-1232. Public Health Service. Hyattsville, MD. December 1983. 



222 



Table 13 

Cigarettes smoked per day by persons 20 years of age and over, according to sex, race, and age: United States, 1965, 1976, and 1980. 

(Data are based on household interviews of a sample of the civilian, noninstitutionalized population.) 



Sex, race, and age 








Cigarettes smoked per day 










Less than 15 






15-24 






25 or more 




1965 


1976 


1980 1 


1965 


1976 


1980 1 


1965 


1976 


1980 1 


Male 








Percent of current smokers 4 








Total 2 ' 3 




















All ages, 20 years and over 5 


30.1 


24.9 


24.2 


45.7 


44.4 


41.7 


24.1 


30.7 


34.2 


20-24 years 


o a n 

. . . . 34. y 


31.6 


32.6 


49.7 


49.9 


47.6 


1 5.4 


18.5 


19.8 


OCT 1 A i mnrn 

<;o-o4 years 


.... ZD. 1 


OK c 

Zo.o 


OO -\ 

Zo. 1 


50.0 


45.8 


46.8 


24.3 


OO -7 

Zo. 1 


on i 


35-44 years 


OO "7 

. . . . Zo. 1 


19.6 


1 7.5 


44.8 


41.2 


41.9 


31 5 


39.2 


40.7 


45-64 years 


.... Zo. 1 


1 o.o 


21 .3 


45.3 


44.1 


35.9 


28.0 


of A 


"•Zo 


65 years and over 


47.1 


39.1 


32.4 


39.0 


42.7 


42.5 


13.8 


18.2 


25.2 


White 




















All ages, 20 years and over 5 


27.7 


22.3 


20.0 


46.3 


44.4 


42.7 


26.0 


33.3 


37.3 


zu-zq years 


no o 

. . . . oZ.o 


0"7 C 

Zl .0 


Zl .0 


50.8 


52.8 


50.5 


1 D.9 


-1 0 -7 

i y / 


00 1 

ZZ. I 


OC O A \tr-\r^rr* 

Zo-oA years 


OO Q 

. . . . ZZ.O 


OO -\ 
ZZA 


\ o.y 


51.1 


46.5 


47.6 


OC i 

Zo. 1 


01 A 

0 1 .4 


00 c 
00.0 


35-44 years 


O -1 o 

.... Z\ .0 


i "7 O 

1 i z 


13.4 


44 8 


40.4 


41.9 


o o n 


A O C 


A A O 
44.0 


45-64 years 


OA 

. . . . ZA.O 


-ICO 

1 O.Z 


-1 "7 O 

1 1.0 


45.4 


43.3 


36.9 


on o 
30. U 


40.4 


45.0 


65 years and over 


44.6 


37.5 


29.0 


40.3 


42.2 


44.0 


15.1 


20.4 


27.0 


Black 




















All ages, 20 years and over 5 


49.8 


43.7 


48.4 


41 .6 


45.6 


37.9 


8.6 


10.8 


13.8 


20-24 years 


52.7 


56.9 


58.6 


41.9 


34.2 


34.5 


*5.3 


*8.9 


6.9 


25-34 years 


47.8 


46.0 


42.0 


41 .7 


43.5 


47.6 


10.5 


10.5 


10.4 


35-44 years 


. . . . 42.5 


38.5 


50.1 


45.5 


44.8 


36.4 


1 2.0 


16.7 


13.7 


45-64 years 


. . . . 46.9 


35.9 


50.4 


43.7 


50.8 


34.4 


9.4 


13.3 


15.2 


65 years and over 


. . . . 64.9 


53.0 


42. 1 


31.9 


47.0 


37.4 


*3.2 




20.9 


Female 




















Total 2 ' 3 




















All ages, 20 years and over 5 


46.2 


37.6 


34.7 


40.8 


43.4 


42.0 


13.0 


19.0 


23.2 


Zu-ZA years 


. . . . 48.4 


43. 1 


43.5 


41.9 


42.4 


40.6 


9.7 


14.5 


1 5.9 


25-34 years 


. . . . 41.4 


34.3 


33.7 


43.1 


45.2 


42.1 


15.5 


20.5 


24.2 


35-44 years 


. . . . 39.1 


33.8 


27.6 


43.7 


44.4 


39.7 


17.1 


21 .8 


00 -7 
■iZ. 1 


45-64 years 


. . . . 44.4 


34.3 


29.6 


42.0 


44.2 


45.5 


1 3 6 


21 .5 


0 a n 
24. y 


65 years and over 


62.6 


49.3 


48.7 


31.0 


38.9 


38.2 


6.4 


11.8 


13.1 


White 




















All ages, 20 years and over 5 


43.7 


34.3 


30.7 


42.4 


44.9 


44.1 


13.9 


20.9 


25.2 


20-24 years 


. . . . 45.3 


39.3 


37.3 


44.4 


44.3 


44.0 


1 0.4 


1 6.4 


1 8.7 


25-34 years 


. . . . 37.9 


30.6 


28.3 


45.4 


46.8 


45.7 


1 6.7 


22.6 


26.0 


35-44 years 


. . . . 36.2 


29.5 


24.1 


45.3 


45.4 


40.5 


1 8.4 


25.1 


35.5 


45-64 years 


. . . . 42.4 


32.0 


25.4 


43.2 


45.1 


47.9 


14.5 


23.0 


26.7 


65 years and over 


61 5 


45.7 


47.6 


31.8 


41.7 


38.4 


6.8 


12.6 


14.0 


Black 








Percent of current smokers 4 








All ages, 20 years and over 5 


70.3 


64.5 


61.1 


25.0 


30.0 


30.4 


4.6 


5.6 


8.6 


20-24 years 


73.4 


65.7 


80.0 


22.1 


31.3 


20.0 


*4.5 


*3.0 




25-34 years 


66.2 


58.8 


59.9 


25.1 


33.6 


229 


8.7 


*7.7 


17.4 


35-44 years 


63.4 


60.4 


57.2 


30.4 


38.1 


34.3 


*6.2 


•1.4 


8.5 


45-64 years 


69.4 


53.2 


56.1 


26.9 


36.7 


33.3 


*3.6 


10.1 


10.7 


65 years and over 


83.2 


100.0 


62.7 


16.8 




37.3 









1 Final estimates. Based on data for the last 6 months of 1980. 
2 Base of percent excludes unknown amount smoked 
includes all other races not shown separately. 

"A current smoker is a person who has smoked at least 100 cigarettes and who now smokes; includes occasional smokers. 
5 Age adjusted by the direct method to the 1970 civilian, noninstitutionalized population using five age groups. 
'Figure does not meet standards of reliability or precision. 

Note: Data in this table should not be compared with data in Health, United States. 1981 or Health, United States, 1982. The 1980 
data in the 1981 edition were preliminary estimates, and the data in the 1982 edition were final estimates but did not include age- 
adjusted data. 

Source: Division of Health Interview Statistics, National Center for Health Statistics Data from the National Health Interview Survey. 
In National Center for Health Statistics: Health, United States, 1983. DHHS Pub. No. (PHS) 84-1232. Public Health Service. Hyatts- 
ville, MD, December 1983. 



223 



Table 14 

Alcohol consumption— percent distribution, 1977. 



Alrohol 
Consumption 




SEX 




AGE 






FAMILY INCOME 




Total 1 


Male 


Female 


20-34 


35-54 

yr. 


55 yr. 
and 
over 


Less 
than 
$5,000 


$5,000- $15,000- 
$14,999 $24,999 


$25 000 
and 
over 


Population 






















(1 ,000) 


139,959 


65,798 


74,162 


51,230 


46,296 


42,432 


18,020 


52,529 


34,630 


21 ,679 










PERCENT DISTRIBUTION 








Frequency 






















of alcohol 






















consumption: 






















Never 


28.6 


21.5 


34.2 


18.9 


25.9 


42.7 


46.2 


OU.4 




14.9 


Occasionally . 


41.9 


35.9 


46.7 


47.3 


42.1 


35.4 


35.0 


42.8 


45.5 


42.5 


1 or 2 times a 






















week 


15.5 


20.2 


11.8 


19.5 


16.1 


10.3 


10.3 


14.8 


17.1 


20.7 


3 or more 






















times a 






















week 


14.0 


22.5 


7.3 


14.3 


16.0 


11.6 


8.5 


12.0 


16.3 


21.9 


Percent who 






















drink 5 or 






















more drinks 






















at one 






















sitting 1 ... 


29.4 


43.1 


18.5 


43.1 


30.2 


12.4 


20.4 


29.2 


33.4 


36.8 



'Includes persons with unknown family income. 

Source U S National Center for Health Statistics, Advance Data from Vital and Health Statistics, No. 64, November 1980 and un- 
published data. In U .S. Bureau of the Census, Statistical Abstract of the United States: 1982-83 (103d edition). Washington, DC, 1982. 



Table 15 

Alcohol— percent of population who are current users: 1972 to 1979. 



Characteristic 




YOUTHS 




YOUNG 
ADULTS 


ADULTS 


1972 


1976 


1979 


1976 


1979 


1976 


1979 


ALCOHOL 2 
















Current users, total 


24 


32 


37 


69 


76 


56 


61 


Male 


27 


36 


39 


79 


84 


63 


72 


Female 


21 


29 


36 


58 


68 


49 


52 


White 


24 


34 


38 


72 


78 


57 


62 


Black and other 


19 


23 


29 


54 


62 


50 


56 


SMSAs with 1 million or more inhabitants 1 


24 


38 


40 


78 


80 


70 


72 


SMSAs with under 1 million inhabitants 1 . 


28 


33 


35 


72 


75 


54 


58 


Nonmetropolitan areas 


20 


26 


35 


55 


71 


41 


51 



1 Refers to standard metropolitan statistical areas as defined in 1970 census publications 

2 For 1972 and 1976, respondent gave answers orally Beginning in 1979, respondent marked answer on a private sheet 
Source: U S National Institute on Drug Abuse, National Survey on Drug Abuse Main Findings, 1979. In U S. Bureau of the Census, 
Statistical Abstract of the United States; 1982-83 (103d edition). Washington, DC, 1982. 



224 



Table 16 

Percent of obese adults ages 20-44 years, by race, sex, and income 
level: United States, 1971-72. 



Percent Obese 



Anp 


White 


Male 


Black 


Inrnmp hplnw nn\/p rt\/ Ip\/pI 1 
m ioui i ic uciuvv ^j^jvci ly itjvci 








90 44 


Q 9 




mo 




I O.n 




^ 1 


Inrnmp ahn\/p nn\/prt\/ Ip\/pM 








90 AA 


17 n 




I I .-J 


45-74 


13.3 




9.7 






Female 




Age 


White 




Black 


Income below poverty level 1 








20-44 


25.1 




35.0 


45-74 


27.6 




32.7 


Income above poverty level 1 








20-44 


18.6 




25.0 


45-74 


24 7 




32.4 



1 Excludes persons with unknown income. 

Source: National Center for Health Statistics: Preliminary Findings of the First Health 
and Nutrition Examination Survey, United States. 1971-1972. DHEW Pub. No. (HRA) 
74-1229. 



225 



References 

1 . Department of Health and 
Human Services, Brandt, 
E.N., Jr., M.D., Assistant 
Secretary for Health. 
"Foreword" to Prevention 
'82. Public Health Service. 
DHHS (PHS) Pub. No. 

82- 50157. 

2. National Center for Health 
Statistics: Health, United 
States, 1980. DHHS Pub. No. 
(PHS) 81-1232. Public Health 
Service. Hyattsville, MD, 
December 1980. 

3. Department of Health and 
Human Services: Public 
Health Service Implementa- 
tion Plans for Attaining the 
Objectives for the Nation. 
Supplement to the 
September-October 1983 
Issue. Public Health Service. 
Washington, DC, 1983. 

4. Taffel, S.: Prenatal care: 
United States, 1969-75. Vital 
and Health Statistics, Series 
21, No. 33. DHEW Pub. No. 
(PHS) 78-1911. Public Health 
Service. U.S. Government 
Printing Office, Washington, 
DC, September 1978. In Na- 
tional Center for Health 
Statistics, Ventura, S.J.: Births 
of Hispanic Parentage, 1980. 
Monthly Vital Statistics 
Report. Vol. 32, No. 6 Supp. 
DHHS Pub. No. (PHS) 

83- 1120. Public Health Serv- 
ice, Hyattsville, MD, 
September 1983. 

5. Ventura, S.J.: Births of 
Hispanic Parentage, 1980. 
Monthly Vital Statistics 
Report. Vol. 32, No. 6 Supp. 
DHHS Pub. No. (PHS) 
83-1120. Public Health Serv- 
ice, Hyattsville, MD, 
September 1983. 

6. "Variation In Use of 
Obstetric Technology," 
Kleinman, J.C., Cooke, M., 
Machlin, S., National Center 
for Health Statistics, and 
Kessel, S.S., National Institute 
of Child Health and Human 
Development. In Health, 
United States, 1983. DHHS 
Pub. No. (PHS) 84-1232. 



Hyattsville, MD, December 
1983. 

7. The Nurse's Reference 
Library: Assessment. 
Intermed Communications, 
Inc. Springhouse, PA, 1983. 

8. National Center for Health 
Statistics: Health, United 
States, 1982. DHHS Pub. No. 
(PHS) 83-1232. Public Health 
Service. Hyattsville, MD, 
December 1982. 

9. Health Care Financing Ad- 
ministration: Leicher, E.S., 
Howell, E.M., Corder, L.S., 
and LaVange, L, "Access to 
Medical Care in 1980." Un- 
published draft, deliverable 
No. 305 B., October 1983. 

10. Health Care Financing 
Administration: O'Brien, M.K., 
Rodgers, J., Baugh, D., 
"Ethnic and Racial Patterns 
in Enrollment, Health Status 
and Health Services Utiliza- 
tion in the Medicaid Popula- 
tion." September 30, 1983. 
Table 10. 

1 1 . Preventive Medicine, 
U.S.A. Task Force Reports 
Sponsored by the John E. 
Fogarty International Center 
for Advanced Study in the 
Health Sciences, National In- 
stitutes of Health and The 
American College of Preven- 
tive Medicine, Prodist Press, 
New York, 1976. 

12. Breslow, Lester: Section 
1502 (8) Prevention in Per- 
sonal Health Services: A Task 
Force Study. In Papers on 
the National Health 
Guidelines, the Priorities of 
Section 1502, U.S. Public 
Health Resources Administra- 
tion. U.S. Government Print- 
ing Office, Washington, DC, 
January 1977. 

13. National Center for Health 
Statistics: Health, United 
States, 1983. DHHS Pub. No. 
(PHS) 84-1232. Public Health 
Service, Hyattsville, MD, 
December 1983. 

14. National Center for Health 
Statistics: Changes in 
Cigarette Smoking and Cur- 
rent Smoking Practices 
among Adults: United States, 



1978. Advance Data, No. 52, 
September 19, 1979. 

15. Abraham, S.: Obese and 
overweight adults in the 
United States. Vital and 
Health Statistics, Series 1 1 , 
No. 230. DHHS Pub. No. 
83-1680. Public Health Serv- 
ice. U.S. Government Printing 
Office, Washington, DC, 
January 1983. 

16. National Center for Health 
Statistics: Health, United 
States, 1979. DHHS Pub. No. 
(PHS) 79-1232. Public Health 
Service. Hyattsville, MD, 
December 1979. 

17. "Obesity and the Life 
Cycle: Infancy and 
Preadolescence," LeBlanc, 
R.E., and Weil, W.B., Nutri- 
tion, Physiology, and Obesity, 
Schemmel, R. (ed.) CPC 
Press, FL, 1980. 



List of Tables 

1 . Percent of population with 
a general checkup within a 
year, by selected characteris- 
tics: United States, 1980. 

2. Percent of persons ages 
25-74 years by race, sex, 
age, and selected tests or 
procedures received during 
checkup: United States, 
1971-1975. 

3. Percent of persons ages 
25-74 years by annual family 
income and selected tests or 
procedures received during 
checkup: United States, 
1971-1975. 

4. Percent distribution of live 
births by month of pregnancy 
prenatal care began and me- 
dian number of prenatal 
visits, by Hispanic origin of 
mother, and by race of child 
for mothers of non-Hispanic 
origin: total of 22 reporting 
States, 1980. 

5. Number of live births and 
percent distribution of live 
births by educational attain- 
ment of mother and median 
years of school completed, 
by Hispanic origin of mother, 
and by race of child for 
mothers of non-Hispanic 
origin: total of 20 reporting 
States, 1980. 

6. Mothers receiving am- 
niocentesis during 
pregnancy, according to age, 
race, and location of 
residence: United States, 
1980. 

7. Mothers with at least one 
ultrasound procedure during 
pregnancy, according to race 
and location of residence: 
United States, 1980. 

8. Mothers with at least one 
medical xray during pregnan- 
cy, according to reason for 
xray, race, and location of 
residence: United States, 
1980. 

9. Change in smoking and 
drinking behavior during 
pregnancy of married 
mothers of live born infants, 



226 



according to selected 
characteristics: United States, 
1980. 

10. Vaccination status of 
children 1-4 years of age, ac- 
cording to race and standard 
metropolitan statistical area 
(SMSA) component: United 
States, 1974, 1976, 1979, 
and 1981. 

1 1 . Self assessment of health 
according to selected 
characteristics: United States, 
1976 and 1981. 

12. Cigarette smoking status 
of persons 20 years of age 
and over, according to sex, 
race, and age: United States, 
1965, 1976, and 1980. 

13. Cigarettes smoked per 
day by persons 20 years of 
age and over, according to 
sex, race, and age: United 
States, 1965, 1976, and 
1980. 

14. Alcohol consumption — 
percent distribution, 1977. 

15. Alcohol— percent of 
population who are current 
users: 1972 to 1979. 

16. Percent of obese adults 
aged 20-44 years, by race, 
sex, and income level: United 
States, 1971-1972. 



List of Figures 

1. Percent distribution of 
married mothers of live born 
infants, according to smoking 
and drinking behaviors 
before and during 
pregnancy: United States, 
1980. 

2. Comparative fatness 
trends of black and white 
female participants in the Ten 
State Nutrition Survey. 



228 



Chapter X 



Utilization of 
Health Services 



Table of Contents 



Overview 231 

A. Introduction 231 

B. Ambulatory Care 232 

1 . Physician Visits 231 

2. Office-Based Physician Visits 232 

3. Outpatient Department/Emergency Room 
' Physician Visits 232 

4. Telephone Contact with Physicians 233 

5. Primary Reason for Physician Encounters 233 

6. Visit Frequency by Physician Type 234 

7. High Utilizers of Physician Services 234 

C. Inpatient Care 235 

1. Discharges from Short-Stay Hospitals 235 

2. Length of Stay within Short-Stay Hospitals 236 

3. Surgical Procedures within Short-Stay 
Hospitals 236 

D. Extended Facility Care 237 
Tables 239 

References 247 
List of Tables 247 



230 



Chapter X 



Utilization of 
Health Services 



Overview 

In this chapter the health 
care utilization patterns of the 
disadvantaged are compared 
with those of the rest of the 
population. Medical care 
utilization is categorized in 
terms of the following modes 
of medical care: (1) am- 
bulatory care; (2) inpatient 
care; and (3) extended care. 

The commitment to an 
equitable distribution of 
health services among the 
total U.S. population has 
spurred an intense interest 
and investigation into the 
volume and patterns of 
health services utilization in 
the United States. Utilization 
of health services is not a 
simple concept. The literature 
is replete with complex defini- 
tions of utilization, contradic- 
tory findings, and a plethora 
of interpretations and 
summaries. 

Since 1964, the number of 
physician visits per person, 
per year remained relatively 
constant up to 1980. For ex- 
ample, in 1964, there were 
4.6 physician visits per year 
per person, and in 1980, 4.7 
visits. The relationship be- 
tween the number of physi- 
cian visits and age is best 
described by a U-shaped 
curve. Old people and the 

! very young tended to use 
more services. High rates of 
obstetric visits by women in 
childbearing years (15 to 44) 

ii increase the rates of physi- 
cian use for this age and sex 
category. Continuing through 
old age, females had more 

i physician visits than males. In 
1964, the poor tended to 
have fewer physician visits 
per person per year than did 
the nonpoor. By 1975, the 
differences between the poor 
and the nonpoor were 
actually reversed. 



The proportion of physi- 
cian visits in offices 
decreased from 69.7 percent 
in 1964 to 67.1 percent in 
1980. Also, greater use was 
being made of physician ser- 
vices in hospital emergency 
rooms/outpatient departments 
and by telephone contact. A 
greater proportion of whites 
than nonwhites consulted 
with physicians in the office 
or by telephone, while pro- 
portionally more nonwhites 
saw physicians in hospital 
clinics or emergency rooms. 

A National Center for 
Health Statistics survey 
reported that in 1971, 1975, 
and 1980 over 80 percent of 
physician visits were for 
diagnosis and/or treatment. 
Most physician visits were 
made to a general practi- 
tioner for medical care, but 
increasingly, patients began 
visiting a specialist. Young 
children were more likely 
than any other age group to 
use specialists; females were 
somewhat more apt to see 
specialists than males; and 
whites made greater use of 
specialists than nonwhites. 

Patients who visit a physi- 
cian five or more times a 
year make a high demand 
on the health system. A com- 
parison among the years 
1967, 1971, 1975, and 1980 
showed no substantial 
change in the percentage of 
persons frequently using the 
system. Both the very young 
and the elderly were high 
utilizers. The proportion of 
high utilizers was about equal 
between whites and blacks. 

The rate of hospital 
discharges for the U.S. 
population was 124.4 per 
1,000 population in 1975, 
and 120.0 per 1,000 popula- 
tion in 1980. Thus there was 
little change over the 5-year 
period. Hospital discharge 



rates were lower for children 
than any other age group; 
the rate was highest in the 
reproductive years and then 
declined until ages 65 and 
over, when it peaked once 
again. By 1980, the percen- 
tage of blacks discharged 
from short-stay hospitals ex- 
ceeded the discharge rate of 
whites by 1 percent. Blacks 
in general averaged longer 
hospital stays. The length of 
hospital stay increased 
steadily with age for blacks 
and whites. 

Sometime in the mid 
1970's, nursing home utiliza- 
tion stabilized after a 10-year 
period of very fast growth. In 
1963, there were 25.4 
residents in nursing homes 
per 1,000 population; in 
1977, 47.9 per 1,000, an 
88.6 percent increase. Fewer 
than 6 percent of the 
residents of nursing and per- 
sonal care homes were non- 
whites, and only one-fourth of 
the residents were male. The 
proportion of the population 
65 years of age and over is 
growing at a faster rate than 
that of other age groups. This 
trend will continue, and 
utilization of nursing homes, 
therefore, will continue to 
increase. 
A. Introduction 
The examination of utilization 
data results in some unique 
insights into the functioning of 
the Nation's health care 
delivery system. Such an ex- 
amination allows an 
understanding of which parts 
of the system get used, to 
what extent, by whom, for 
what, and why. Although 
utilization data are analyzed 
with respect to special health 
problems in other chapters of 
this book, utilization is a topic 
in itself when assessing the 
health status of subpopula- 
tions of our society. 



Utilization data have been 
interpreted in a number of 
ways that lead to varying 
conclusions. There are those 
who contend that higher 
utilization indicates higher 
levels of morbidity, since it is 
need that dictates the use of 
health services. On the other 
hand, there are those who 
argue that certain need levels 
have always existed, but that 
health services were not 
always available or accessi- 
ble for many people. Thus 
higher utilization may indicate 
the improved availability and 
accessibility of medical care. 
As stated in "Changes in 
Morbidity, Disability, and 
Utilization Differentials Be- 
tween the Poor and the Non- 
poor," by Wilson and White, 
"It is interesting that in the 
dental area, where there 
have been only minimal ef- 
forts to increase access to 
care, there have been no 
major changes between the 
poor and the nonpoor in the 
amount of dental care 
received. On the other hand, 
for hospital and physician 
care, where more program 
efforts have taken place, 
there have been reductions 
or eliminations of differences 
in utilization between the 
poor and the nonpoor." (1, 
p. 641) 

This latter interpretation 
leads to the inference that in- 
creased utilization will result 
in improved health status. 
Some health economists 
would state another point of 
view: that the relationship 
between utilization and health 
status is a negatively ac- 
celerated function. That is. in- 
creased utilization leads to 
improved health status up to 
a point, but further utilization 
results in no additional health 
status improvements. Even if 



231 



this position is correct, it is 
obvious that, at least tor 
racial/ethnic minorities and 
the disadvantaged, we have 
not as yet reached that part 
of the curve for many health 
problems where increased 
utilization has no effect. 

This chapter on utilization 
presents data on the patterns 
of use of medical services 
among minority groups com- 
pared with the remainder of 
the population. What is not 
addressed is the complex 
issue of the need for medical 
care as it relates to the use 
of medical services. Even 
though utilization rates have 
increased substantially for 
minorities and low income 
groups, the higher levels of 
morbidity among these 
populations appear, at least 
partly, to be the result of 
unmet medical needs. 
Minorities' use of health serv- 
ices has increased, and 
many measures indicate that 
there has been a concomi- 
tant improvement in their 
health status. Nevertheless, 
their health status is still not 
as high as that of the white 
majority. 

Additional caveats on the 
interpretation of the data 
presented are contained in 
Chapter I of this book. 
B. Ambulatory Care 
1. Physician Visits 
Over a 16-year time span, 
from 1964 to 1980, there was 
no substantial increase in the 
average number of per per- 
son physician visits (see 
Table 1). In 1980, there were 
approximately 1 billion patient 
contacts with medical doctors 
(excluding visits to inpatients 
in hospitals), an average of 
4.8 visits per person. This 
rate is similar to that reported 
in 1964 (4.6 visits). Although 
the total visit rate remained 
static, there were patterns of 
change occurring among 
cohorts of the population. For 
example, Americans earning 



over $25,000 steadily 
decreased their number of 
visits within this time period, 
while those at the other end 
of the family income scale, 
those earning less than 
$7,000, increased their 
number of visits. Between 
1965 and 1980, physician 
visits per person per year in- 
creased from 3.9 to 5.5 for 
lower income persons. Thus 
in 1964 the poor tended to 
have fewer physician visits 
per person per year than did 
the nonpoor. By 1975, 
however, the differences be- 
tween the poor and the non- 
poor were actually reversed. 

Each of the categories 
within each of the 
demographic variables listed 
in Table 1 reflects an in- 
crease in per person visits 
between 1964 and 1975, 
with the exception of persons 
65 years and over, and those 
with family incomes of 
$25,000 and over. Each of 
the categories within each of 
the demographic variables 
either remained the same or 
showed a decrease in per 
person visits for the years 
1975 to 1980 (except pa- 
tients under 1 7 years of age). 
One interpretation of these 
data is that utilization of 
physician services is sensitive 
to the economy. Thus the 
reversals in the economy that 
occurred from 1975 to 1980 
would have affected the 
general trend toward greater 
physician utilization. 

Another characteristic of 
physician services utilization 
is that it is directly related to 
age groups. For each of the 
reported years— 1964, 1975, 
1980— the number of physi- 
cian contacts per person per 
year increased for each 
higher age group. In 1980, 
the rates ranged from 4.4 for 
persons under 17 years to 
6.4 for persons 65 years and 
over. Also, females continued 
to have more per person 
visits to a physician than 
males. Females had an 



average visit rate of slightly 
over one more visit per year 
than males in 1964, 1975, 
and 1980. In the past, this 
higher utilization rate seemed 
to be due to only one factor, 
visits for prenatal and 
postnatal care and 
associated problems. With 
the passage of time, an addi- 
tional factor appears to be 
having an effect: age. The 
aged population is a higher 
utilizer of physician services, 
and because of the greater 
longevity of females, a larger 
component of that age group 
is female. 

In 1964, residents in the 
West had the highest per 
person physician visit rate, 
with 5.5 visits per year, com- 
pared with 4.3 in the South, 
the region with the lowest 
rate. By 1980, the visit rate 
had decreased in the West 
and increased in the South to 
the point where the rates 
were somewhat similar (West, 
4.9; South, 4.6). Actually, by 
1980 there was little regional 
variation in the annual 
number of physician visits. 
2. Office-Based Physician 

Visits 

The majority of people 
visiting a physician do so in 
the doctor's office. In the Na- 
tional Health Interview 
Survey, an office refers to the 
office of any physician in 
private practice, including 
physicians connected with 
prepaid group practices (2, 
p. 77). In 1980, 67.1 percent 
of all physician visits took 
place in the doctor's office, 
while only 13.1 percent of 
visits occurred in an outpa- 
tient department or 
emergency room, despite the 
fact that outpatient depart- 
ments and emergency rooms 
are becoming popular 
centers for physician visits (3, 
p. 128). 

The proportion of people 
seeing a physician in his or 
her office also has remained 
relatively constant over the 
period from 1964 to 1980. 



Over that period, a greater 
percentage of whites than 
blacks saw a physician at the 
office. Also, more of the non- 
poor had office visits than the 
poor. The high cost of office- 
based medical care may be 
one factor accounting for 
these differences. Visits to 
many other settings for health 
care usually are financed 
totally through third-party 
coverage. Also, as people 
get older, they have more of 
their physician contacts in a 
doctor's office. This may be 
due to their clinging to 
established patterns of health 
services utilization. It is impor- 
tant to note that the Medicare 
programs were not im- 
plemented until 1966. Some 
of the changes after 1964 in 
physician utilization noted 
above probably reflect the 
impact of these programs. 

A larger proportion of 
nonmetropolitan residents 
than metropolitan residents 
visited a physician in a physi- 
cian's office in 1964, 1975, 
and 1980. 

3. Outpatient Department/ 
Emergency Room 
Physician Visits 

As reported earlier, there is 
an increasing trend (albeit a 
slowly increasing trend) for 
physician visits to take place 
in hospital outpatient depart- 
ments and emergency 
rooms. The groups using this 
treatment setting in greater 
proportions are the converse 
of those using physicians' of- 
fices: a greater percentage of 
younger patients than older 
patients use this setting; a 
greater percentage of males 
than females; a greater 
percentage of blacks than 
whites; a greater percentage 
of the poor than nonpoor; a 
greater percentage of those 
in the Northeast region than 
other geographic regions, at 
least recently; and a greater 
percentage of urban than 
rural residents. 

From 1964 to 1980, there 
has been only a slight in- 



232 



crease in the use of the 
hospital outpatient depart- 
ment and emergency room 
(12.2 percent of the physician 
visiting population in 1964, 
and 13.1 percent in 1980). 
There are, however, cohorts 
of the population that have 
shown significant increased 
usage over the years: each 
age group, except those 
under 17, shows a small but 
steady proportional increase 
in emergency room/outpatient 
department usage; the 
percentage of males using 
these facilities for a physician 
visit also shows a small but 
steady increase (13.2 percent 
in 1964; 15.4 percent in 
1980), as do those in the 
higher income brackets; and 
patients living in the North- 
east have also increased their 
visits to these locations (10.1 
percent in 1964; 15.7 per- 
cent in 1980). 

Many of these increases 
may be due to the manner in 
which physicians use these 
facilities relative to their 
originally intended purposes. 
Emergency rooms, for exam- 
ple, were initially established 
for providing care to trauma 
victims and patients with 
acute conditions. Now physi- 
cians refer their patients to 
the hospital emergency room 
or outpatient department for 
several reasons, including in- 
ability to accommodate the 
patient within the daily office 
schedule, the availability of 
better equipment, and some 
physicians, unwillingness to 
accept certain third-party 
payers. 

Although the percentage 
of blacks using hospital out- 
patient facilities for physician 
visits is clearly greater than 
the percentage of whites, the 
proportion of black usage 
has decreased from 1964 
(32.7 percent) to 1980 (26.2 
percent). Many have 
predicted that black and 
white use of emergency 
room/outpatient department 
service will converge over 



time. Although the data in- 
dicate that this is occurring, 
the convergence appears to 
be taking longer than other 
white/black utilization trends. 
4. Telephone Contact with 

Physicians 
By National Health Interview 
Survey definition, telephone 
contact with a physician con- 
stitutes a physician visit even 
though there is no physical 
encounter between the physi- 
cian and the patient (4, p. 
53). Between 1964 and 
1980, the proportion of 
telephone contacts increased, 
but not greatly (1.8 percent). 
A greater percentage of the 
very young used the 
telephone (presumably the 
call was made on their behalf 
by an adult) for physician 
contact than did the elderly. 
In 1980, 17.3 percent of 
those under 17 years used 
the telephone, compared to 
8.9 percent of those over 65 
years of age. Over the years, 
a greater percentage of the 
young have always used 
telephone contact for physi- 
cian advice. Of interest are 
the changes over time that 
occurred between the young 
and the elderly. More pa- 
tients aged 17 to 44, and 
more of those aged 45 to 64, 
used the telephone in 1980 
than in 1964, a respective in- 
crease of 3.2 percent and 
4.1 percent. 

A larger proportion of 
females than males has 
always used the telephone 
for physician contact, 
although the proporticn of 
male usage increased a full 
2 percent from 1964 to 1980 
(9.3 percent in 1964; 1 1.3 
percent in 1980). 

Proportionately far fewer 
blacks than whites contacted 
a physician by telephone; 
however, the percentage of 
physician telephone contacts 
by blacks increased from 4.2 
percent in 1964 to 5.5 per- 
cent in 1980. Despite this in- 
crease, there continues to be 
a large gap (an 8.3 percent 



difference) between 
telephone contact by blacks 
and whites. In 1975, a 
substantially larger proportion 
of blacks used the telephone 
for physician advice; in that 
year, however, whites also in- 
creased their usage and so 
the gap between the two 
groups remained. 

Over time a consistently 
greater percentage of those 
patients in the higher income 
groups use telephone physi- 
cian contact than patients in 
the lower income groups. A 
change is occurring, 
however, among the lower in- 
come groups. A much larger 
proportion of families earning 
less than $10,000 used 
telephone contacts in 1980 
than in 1964. A steady in- 
crease in telephone usage is 
also obvious among the 
population residing in 
nonmetropolitan areas. 
5. Primary Reasons for 

Physician Encounters 
"In the National Health Inter- 
view Survey, respondents 
who reported a physician 
visit were asked why they 
consulted a physician. 
Responses to that question 
were classified into the follow- 
ing type of service 
categories: diagnosis or treat- 
ment; prenatal and postnatal 
care; general checkup; im- 
munization and vaccination." 
(5, p. 26) Except for the 
diagnosis or treatment 
category, all of the categories 
include physician visits made 
by persons who are practic- 
ing at least some of the basic 
notions of good preventive 
health care. Chapter IX 
discusses patients making 
physician visits for preventive 
health care. 

More than 80 percent of 
the physician visits across the 
9 years reported in Table 2 
were made for diagnosis and 
treatment. Diagnosis or treat- 
ment of conditions had been 
the predominant reason that 
physicians were consulted 



over the years studied, ac- 
counting for 81.4 percent of 
all physician visits in 1971; 
84.9 percent in 1975; and 
84.4 percent in 1980. 

In almost every data set, 
females are shown to use the 
system more than males. For 
visits relating to diagnosis 
and treatment, however, a 
lower percentage of females 
than males saw a physician. 
In 1980, there was a 5.5 per- 
cent difference between 
females and males seeking 
diagnosis or treatment from a 
physician. The percentage of 
both sexes seeking diagnosis 
and treatment increased from 
1971 to 1980, but, still, a 
greater percentage of these 
were males. 

When examining the age 
characteristics of visits for 
diagnosis and treatment, a 
pattern becomes obvious. 
Those under 35 years of age 
had a noticeably smaller pro- 
portion of diagnosis and 
treatment visits in the last 
decade than persons over 35 
years of age (a 10 percent 
difference obtained in 1971 
and 1980, although the dif- 
ference was less in 1975). 
The only exception to this 
pattern was the 5- to 14-year- 
olds, whose proportions of 
visits for these purposes were 
closer to those of the 35- to 
44-year-old bracket. In the 
upper age groups, very high 
proportions of patients visited 
a physician for purposes of 
diagnosis and treatment, and 
these age groups most often 
visited for the treatment of 
chronic conditions. 

There does not appear to 
be much of a difference in 
this category between blacks 
and whites. Although there 
was a 5.4 percent difference 
between the poor and non- 
poor at the beginning and 
middle of the decade, that 
difference had narrowed to 
1.8 percent by the end of the 
decade. 



233 



As might be expected, a 
greater proportion of visits for 
diagnosis or treatment were 
made by persons unable to 
carry on a major activity. 
Visits for these purposes pro- 
portionally decreased as the 
gradation of activity limitation 
itself decreased. 

When looking at the data 
for the Nation's various 
geographic regions, it is ob- 
vious that the differences are 
small, diminishing from 2.7 
percent in 1971 to 1.7 per- 
cent in 1980. No distinct pat- 
terns emerge from these 
data. 

6. Visit Frequency by 
Physician Type 

For all specialties of office- 
based ambulatory care, more 
visits per person were made 
in both 1975 and 1980 to 
family and general practice 
physicians (GP's) than any 
other specialty (see Table 3). 
The rate had decreased by 
0.25 visits per person be- 
tween 1975 and 1980. Still, 
the lower 1980 rate was 
about three times greater 
than the second most utilized 
specialty, internal medicine. 
While this rate of visits per 
person has decreased for 
GP's, it has increased for 
every specialty except 
general surgery. The special- 
ty showing the greatest in- 
crease from 1975 to 1980 in 
visits per person is pediatrics. 

Each of the higher age 
groups reflected less usage 
from 1975 to 1980 of the 
family and general practice 
specialty. Although the reduc- 
tion is not as dramatic, the 
specialty of general surgery 
also reflects less usage for 
each age group. Among 
children under 15 years of 
age, there was a sharp rise 
in the rate of visits to a 
pediatrician from 1975 to 
1980, and a substantial 
decrease in visits to family 
practitioners. About a one- 
half-visit-per-person decrease 
for GP's occurred within the 



45-65 age group. It should 
be noted that the identical 
decrease occurs for this age 
group's rate of visits to all 
specialties combined. The 
rate of visits increased with 
each incremental age group 
in both 1975 and 1980 for 
general and family practice, 
internal medicine, and 
general surgery. This did not 
occur, obviously, for 
obstetrics and gynecology, 
since this specialty is both 
sex and age selective. Of 
course, visits per person to 
office-based physicians in- 
creased with age, as shown 
in Table 1; Table 3 simply 
delineates what type of office- 
based physician these age 
groups visited. 

Both males and females 
decreased their visits to GP's 
from 1975 to 1980 while 
slightly increasing their use of 
internists. In this period, both 
sexes also decreased their 
visits to general surgeons, 
although the female decrease 
was about twice that of the 
male. A greater percentage 
of females visited a doctor's 
office in both years, and they 
made more visits than males 
did to physicians specializing 
in family practice, internal 
medicine, general surgery 
and, of course, obstetrics 
and gynecology. 

With respect to race "all 
other" races contributed 
more to the decrease of GP 
usage from 1975 to 1980 
than whites did (whites 
manifested a 0.23 visit per 
person decrease; "all other" 
showed a 0.35 per person 
visit decrease), while both 
racial groups contributed 
almost equally to the decline 
in general surgery usage 
(whites showed a 0.07 visit 
per person decline; "all 
other" showed a 0.05 
decline). Whites are 
somewhat more responsible 
for the increased rate of visits 
to an office-based pediatri- 
cian than "all other" (a 0.12 
per person increase for 



whites during the reported 
time interval, and a 0.08 in- 
crease for "all other"). 

There are indications 
across all demographic 
variables of an increased use 
of specialty physicians. 
Perhaps this represents the 
long-term, overall trend 
toward increased proportions 
of specialty physicians, and 
possibly it also represents a 
change in that part of health 
education that deals with 
health care delivery system 
usage. That is, it is likely that 
more people recognize the 
differences among the 
specialties and when to use 
these specialties for certain 
symptoms. 
7. High Utilizers of 

Physician Services 
"Higher frequencies of 
disease as well as more 
severe maladies require more 
frequent visits, whereas 
whether or not any visit took 
place is more sensitive to the 
use of services for preventive 
purposes." (6, p. 44) Thus, 
data and analyses for the 
time interval since- the last 
physician visit are found in 
Chapter IX, "Preventive 
Health." Presented here is in- 
formation about those pa- 
tients who make a high de- 
mand on the health system, 
defined by data sources as 
those who visit a physician 
five or more times in a 
reported year (see Table 4). 
These patients use the 
system more than most of 
the population, presumably 
for illnesses from chronic 
conditions, illnesses of great 
seventy, or several incidents 
of symptoms requiring 
medical attention. 

A comparison of the 
reported years in Table 4, 
1967, 1971, 1975, and 1980, 
shows no substantial change 
in the proportion of persons 
who visited a physician five 
or more times throughout 
each of the years. These 
high utilizers represent about 
20 percent of the population. 



Thus these visits are concen- 
trated within a relatively small 
proportion of the population. 

A higher proportion of 
females than males had five 
visits or more (there was an 
8 percent difference between 
the sexes in 1980). Since 
these data- are not age 
specific, it is impossible to 
determine the extent to which 
the high utilization for females 
occurs during the childbear- 
ing years. The fact that the 
25-34 age group has 
elevated rates of usage com- 
pared to the general age- 
related trend indicates that 
there probably is some effect 
from childbirth. 

The consumption of physi- 
cian services is traditionally 
high among children and the 
elderly. For each of the 4 
reported years, the rate was 
high for children under 5 
years of age, and another 
peak occurred for the age 
group 65 years and over. 
Generally, about 30 percent 
of the children (those under 5 
years of age) are high 
utilizers; 30 percent of those 
age 65 to 74 are high 
utilizers; and 30 percent of 
those over 75 are high 
utilizers. 

To determine poor and 
nonpoor categorization, the 
Statistical Abstract of the 
United States was examined 
for poverty level data for the 
reported years in this 
analysis. The poverty levels 
for these years were reported 
as $3,435 for 1967 (deter- 
mined by averaging the 
respective poverty level in- 
comes for 1966 and 1968); 
$4,137 for 1971; $5,500 for 
1975; and $8,414 for 1980 
(7, p. 440). The broad family 
income categories included 
in the National Health Inter- 
view Surveys used for this 
analysis do not precisely 
match the above poverty 
level figures. Some liberty 
has been taken, therefore, to 
a match the numbers so 
some observations can be 



234 



made about the utilization 
rates of the poor and 
nonpoor. 

In 1967, there was little 
difference (1.8 percent) in the 
proportion of poor who made 
five or more visits to a physi- 
cian throughout the year. In 
1980, there was a 6.0 per- 
cent difference. The percen- 
tage of both poor and non- 
poor high utilizers increased, 
but the poor high utilizers in- 
creased at a greater pace. 
Some of this proportional in- 
crease among the poor may 
be attributable to the effect of 
Medicaid programs. 

Once these Medicaid pro- 
gram s. we r_e- initiated, im- 
plemented, and accepted, 
the continual effect must be 
noted. Poor patients, for ex- 
ample, for whom some finan- 
cial barriers were lifted, came 
to be treated over many 
years for chronic conditions 
which were diagnosed at 
their first visit(s) to physicians 
under the Medicaid plan. 
There was also a continuing 
expansion of Medicaid enroll- 
ment throughout the mid to 
late 1970's. In 1970, the ratio 
of Medicaid recipients to the 
population below the poverty 
level was 0.59. By 1976, the 
ratio increased to 0.91 (8, p. 
48). 

In 1967, a larger percen- 
tage of whites than nonwhites 
were high utilizers of the 
physician visit sector of the 
ambulatory care system. At 
that time, a 5.6 percent dif- 
ference was reported (20.4 
percent for whites, 14.8 per- 
cent for nonwhites). In 1980, 
that gap was almost 
eliminated: 20.9 percent of 
whites had five or more visits 
compared to 20.5 percent of 
nonwhites. Since the closing 
of this gap was systematic 
across the 13-year period, 
the effect is probably real. 

As may be expected, a 
higher proportion of persons 
with major activity limitation 
have five or more physician 
visits than persons with no 



activity limitation. The dif- 
ferences are significant and 
dramatic. Of those patients 
who are unable to carry on a 
major activity, such as keep- 
ing house or working, about 
50 percent have been seeing 
a physician five or more 
times per year. In contrast, 
only 16.6 percent of those 
not limited in activity were in 
the high utilization category. 
The proportional decrease in 
physician visits among those 
not limited in activity (from 
25.3 percent in 1967 to 16.6 
percent in 1980) may in- 
dicate an actual decline in 
the incidence of activity- 
limiting conditions, or it may 
indicate that successful 
rehabilitation services or cor- 
rective treatments were per- 
formed while the person was 
in previous years counted 
among those limited in 
activity. In the early periods, 
about twice the percentage 
of persons in the "high 
activity limitation" group, 
compared with the "no activ- 
ity limitation" group made 
five or more physician visits. 
That differential, however, 
has increased over time. In 
the later periods, the percent- 
age of persons in the "high 
activity limitation" group who 
made five or more visits is 
approximately three times 
that of the "no activity limita- 
tion" group. 

During the reported year, 
1967, there were some ob- 
vious differences among the 
geographic regions for high 
users of physicians' services. 
Persons residing in the 
South, for example, had a 
lower proportion of high 
utilizers (17.5 percent) than 
those in the West (22.1 per- 
cent). For the last reported 
year, 1980, there was no 
discernible difference among 
the four geographic regions. 

A large-scale view of the 
data reveals both a long-term 
trend, and a short-term trend. 
Within the long-term trend, 
some demographic sub- 



categories showed systematic 
increases in the proportion of 
persons who were high 
users, and some showed a 
decrease. Overall, there was 
an increase of 1.1 percent 
across the time period, and 
both sexes demonstrated that 
increase (although females 
showed more of an increase). 
The increase was also 
demonstrated by the two 
lower age groups (below 15 
years of age), and the three 
highest age groups (over 54 
years of age), but the age 
groups in between (15 to 55 
years of age) showed a 
decrease in the proportion of 
high users. The poor revealed 
a decrease, and the nonpoor 
a very modest decrease. 
Nonwhites reported an in- 
crease, and whites a modest 
decrease. The upper two 
categories of activity limitation 
showed an increase, the 
lower two categories a 
decrease. All of the 
geographic regions showed 
an increase, except the West, 
which showed a decrease. 
Thus it appears that all of the 
generally high-user groups 
were showing increases, 
while the low-user groups 
were showing no changes or 
were showing decreases, 
sometimes drastically. 

The short-term trend has 
been obvious in most of the 
utilization data reviewed. That 
is, a fairly large increase in 
health care utilization occurreo 
in the early to mid 1970's 
followed by a return to 
pre-1970 levels by the end of 
the decade. We might sur- 
mise that the increase in the 
middle of that period was 
due to the effects of the 
Medicare and Medicaid pro- 
grams, and the decrease at 
the end to the downturn of 
the economy. If this is cor- 
rect, there should be a return 
to the increased utilization 
following improvements in the 
Nation's economy. 



C. Inpatient Care 

1. Discharges from Short- 
Stay Hospitals 

"While the findings for physi- 
cian visits suggest variations 
in access to ambulatory care 
services, hospitalization data 
reflect who makes the 
greatest demand upon the 
more intensive (and expen- 
sive) inpatient care services." 
(14, p. 120) In recent years, 
those most obviously making 
that demand were the elderly 
and the poor. These are the 
groups, of course, with 
relatively high proportions of 
persons with severe 
morbidity. 

"Although ambulatory 
health care appears to offer 
better prospects for emphasis 
than inpatient hospital care 
because it provides some 
prevention and much earlier 
detection of disease, it is in 
inpatient care that the major 
part of medical care expen- 
diture, both capital and 
operating is incurred at pre- 
sent. Increased emphasis on 
ambulatory care and the 
avoidance of inpatient care 
can be expected to reduce 
the overall costs, and it is of 
interest, therefore, to examine 
the variations in hospital 
use ..." (15, p. 90) These 
variations are examined in 
Table 5 relative to discharges 
from short-stay hospitals over 
a 5-year period from 1975 to 
1980. 

The total number of 
hospital discharges showed a 
slight decline from the begin- 
ning to the end of the 5-year 
reported period (124.4 per 
1,000 population in 1975, 
and 120.0 per 1,000 in 
1980). Annual rates of 
discharges increased 
significantly with each older 
age group for both years. 
Discharge rates for patients 
65 years or older were 
almost 4.5 times greater than 
those for patients 1 7 and 
younger in 1980. Although 
each of the age groups 



235 



demonstrated a proportional 
decrease of use in the 5-year 
period between 1975 and 
1980, the oldest patients 
reported a 2.7 percent in- 
crease, while the other age 
groups each reflected a 
decrease. 

There were proportionally 
more female than male 
hospital discharges in both 
years, although the dif- 
ferences were not great (a 
1 .4 proportional difference in 
1975, decreasing to 0.2 in 
1980). The differences noted 
between the sexes are not 
due to births, since delivery 
discharges were excluded 
from the summary data in 
Table 5. While the proportion 
of male discharges was 
either increasing slightly or 
remaining static, the female 
rate dropped. 

While black discharges 
from 1975 to 1980 either re- 
mained static or increased 
slightly, the disparity between 
white and black discharge 
rates doubled (from 0.5 to 
1 .0 percent), but the dif- 
ferences remain slight. 

Approximately 50 percent 
more low income persons 
had hospital discharges than 
those at the top of the in- 
come scale; the ratio 
remained relatively constant 
during the time period. In 
both 1975 and 1980, there 
was a 5.5 percent difference 
in the discharge rate between 
these two economic groups. 
All age groups manifested a 
decrease in the proportion of 
hospital discharges during 
the period studied, probably 
reflecting the economic 
changes noted in the 
previous section of this 
chapter. 

Discharges from short-stay 
hospitals by geographic 
region were proportionally 



highest in the South in both 
1975 and 1980. Also, each 
of the other regions reported 
decreased discharges (large- 
ly in the West, with a 2.1 per- 
cent decrease), while the 
South's appeared to increase 
slightly. The South was the 
only region not to post a 
decrease in proportions of 
discharges over the time 
period. As for location of 
residence, those outside 
SMSAs increased their 
hospital discharges by 0.5 
percent, while residents of 
SMSAs decreased their pro- 
portion almost a full percent, 
causing nonurban residents 
to proportionally exceed 
those within SMSAs by a 
ratio of 1 :28. 
2. Length of Stay within 

Short-Stay Hospitals 
There was a decline in the 
average length of stay from 
7.5 days to 7.1 days during 
the 5-year period 1975 to 
1980 (see Table 6). The 
decline cut across most 
demographic categories, but 
seemed greater among the 
groups that are the high 
health service utilizers: the 
elderly, those with the lowest 
family income, females, 
blacks, Northeasterners, and 
SMSA residents. Perhaps the 
demographic category that 
manifested the most dramatic 
drop was the elderly, who 
had an average length-of-stay 
decrease of 2 days. 

The poor (those with in- 
comes less than $7,000) also 
continue to place a high de- 
mand on hospital care with 
their longer lengths of stay. 
Like the elderly, however, 
they have reduced their 
hospital bed time from 9.6 
days in 1975 to 8.4 days in 
1980. In 1980, low income 
people remained in the 
hospital an average of 2.4 
days longer than those in the 
highest income group, prob- 



ably because of the lower 
health status of these 
individuals. 

Length of stay declined 
for both blacks and whites 
from 1975 to 1980; however, 
blacks continued to remain in 
the hospital an average of 
more than 2 days longer 
than whites did. The ratio 
between these two racial 
groups, however, appeared 
to drop slightly (from 1.36 to 
1.33). 

Female length of stay 
decreased by 0.7 days from 
1975 to 1980, while the male 
average length of stay re- 
mained constant. By 1980, 
females spent almost 1 .5 
fewer days in the hospital per 
hospitalization than males 
did, excluding the effects of 
deliveries. If deliveries were 
included in the data, the 
female length of stay would 
be even more reduced, caus- 
ing the disparity between 
males and females to be 
even greater. 
3. Surgical Procedures 

within Short-Stay 

Hospitals 
Part of the increase in 
hospital use can be attributed 
to higher surgery rates. 
These rates have continued 
to rise over time, overall at a 
slow but steady pace, and by 
some selected characteristics 
at an alarmingly fast pace. All 
of this is of particular con- 
cern, since the data for both 
acute and chronic conditions 
reveal no change in the 
prevalence of conditions that 
would lead to the sudden 
need for surgical intervention. 
This greater occurrence of 
surgery over the past years 
may be due to more, and 
highly sophisticated, medical 
technology, increased 
specialization among physi- 
cians, and advanced surgical 
techniques. 



In Table 7, surgical rate 
data are presented for 1975 
and 1980. There are two ma- 
jor differences between these 
data and the hospital utiliza- 
tion data presented 
previously in this chapter. 
One difference is that the 
previous tables excluded 
delivery data, Table 7 in- 
cludes them. The second dif- 
ference is that the previous 
tables were derived from in- 
formation collected by the 
National Health Interview 
Survey, whereas Table 7 is 
"based on data collected 
through the National Hospital 
Discharge Survey, a con- 
tinuous survey that has been 
conducted by the National 
Center for Health Statistics 
since 1965. The data for the 
survey are obtained from the 
fact sheets of a sample of the 
medical records of inpatients 
discharged from a national 
sample of short-stay general 
and specialty hospitals in the 
United States."(9, p. 1) 

Questions have been 
raised about the quality of 
data from this source for a 
number of reasons, including 
the assertion that the 
abstracts of such records are 
frequently prepared by 
undertrained, under- 
motivated, and under-paid 
hospital clerks. One indica- 
tion of the quality of the data 
presented in Table 7 is that 
almost 12 percent of the data 
for race were not collected (a 
proportion almost equivalent 
to the nonwhite proportion of 
discharges). There is no 
reason to believe, however, 
that the quality changed be- 
tween the beginning and the 
end of the time period, so 
the conclusions that are 
drawn below are probably 
legitimate despite the sources 
of inaccuracy in the data 
generally. 



236 



In referring to Table 7, 
only the data in the last col- 
umn, the percent column, are 
used for comparisons, both 
between the years and 
among the characteristics. 
The use of this percent col- 
umn is in response to a sug- 
gestion found in the literature 
which accompanied the data: 
"These last figures are in- 
cluded to provide data that 
are comparable with what is 
published for years prior to 
1979." (16, p. 8) 

In the 5-year period from 
1975 to 1980, hospital 
discharges rose over 11.1 
percent, while surgical rates 
among discharges rose over 
19.8 percent. Almost 45 per- 
cent of hospitalized patients 
received surgery in 1980. 
The age group that 
demonstrated the largest pro- 
portional increase, and a 
significant one, is the 15 to 
44 age group. Over the 
5-year period, their propor- 
tion of surgical discharges in- 
creased almost 10 percent. 
There was a slight increase 
among the proportion of 
elderly discharges who 
received surgery, but a 
decline among the remaining 
two age groups. No more 
than 20.4 percent of the in- 
crease in the 15 to 44 age 
group was due to pro- 
cedures relating to childbirth 
(approximately 2,289,000 
more surgical procedures for 
this group and approximately 
468,000 additional births, 
some of which were to 
women outside this age 
group). The surgical rates for 
males remained relatively 
constant; the rates for 
females rose 13.6 percent. 
The number of births in 1980 
reflected a 14.9 increase 
over 1975, making up more 
than the increased surgical 
rate between those two 
years. 



The highest percentage of 
persons having had surgery, 
for both 1975 and 1980, oc- 
curred in hospitals in the 
West, but that region did not 
show the greatest change in 
surgical rates. The South had 
a 10.5 percent increase in 
surgical rates between 1975 
and 1980, the North Central 
region had a change of 0.7 
percent, the West a change 
of 8.3 percent, and the 
Northeast the smallest of 
change, 3.5 percent. 
D. Extended Facility Care 
"Long term care facilities in- 
clude long-stay psychiatric 
and other hospitals (i.e., 
hospitals with an average 
length of stay of 30 days or 
more), nursing homes, 
facilities for the mentally 
retarded, homes for depen- 
dent children, homes or resi- 
dent schools for the emo- 
tionally disturbed, resident 
facilities for drug abusers or 
alcoholics, and various other 
institutions. Inpatient long 
term facilities provide continu- 
ing care for patients who are 
not expected to improve 
mentally or physically, and 
extended care to help pa- 
tients who are ready to return 
home but still need some 
nursing or therapy services 
on a regular basis. 

"Most extended care 
facilities are in nursing 
homes. Nursing homes pro- 
vide both restorative care for 
convalescing patients and 
continuing care for the elder- 
ly. Nursing care homes pro- 
vide less intensive nursing 
and medical services than 
acute care hospitals. These 
homes have multiplied as the 
demand for these services by 
the elderly population has in- 
creased. The trend of greater 
demand is expected to con- 
tinue in the future as life ex- 
pectancy increases. Three 
reasons for greater use of 



these services are: Medicare 
and Medicaid cover these 
services, third-party payers 
apply pressure on short-stay 
hospitals to discharge pa- 
tients no longer needing 
acute care services, and 
relatives may be unable or 
reluctant to care for their own 
elderly." (10, p. 131) 

Numbers, percentage 
distributions, characteristics, 
etc., of patients within some 
of the long-term institutions 
mentioned above are 
discussed in Chapter VIII. In 
this section, attention is 
focused on the elderly, par- 
ticularly those residing on a 
long-term basis in nursing 
homes. In 1977, the National 
Center for Health Statistics 
conducted a nationwide sam- 
ple survey of nursing homes. 
These are the most current 
data available pertaining to 
nursing home utilization. 
Other data relating to the 
elderly— health status, mobili- 
ty, living arrangements, 
etc.— have been collected 
through the National Health 
Interview Survey. 

The proportion of the 
population 65 years of age 
and over is growing at a 
faster rate than that of other 
age groups, and the propor- 
tion 85 years of age and 
over is growing even more 
rapidly. According to the 
Bureau of the Census, in 
1981 those 65 years of age 
and over made up 1 1 per- 
cent of the population (11, p. 
27). This trend is expected to 
continue, and it is predicted 
that 25 percent of the elderly 
will be institutionalized at 
some time during their later 
years (12, p. 504). If this 
prediction is accurate, then 
utilization of nursing homes 
will increase at a very rapid 
rate. 



Table 8 reports the 
number of elderly nursing 
home and personal care 
home residents for the years 
1963, 1969, 1973-74, and 
1977. Over this 14-year 
period, the number of nurs- 
ing home residents increased 
an astounding 153 percent. 
The increase in the popula- 
tion over 65 from 1963 to 
1977 was approximately 36 
percent. Thus not even one- 
quarter of this increase 
represents the proportional 
increase of the elderly 
population over this period of 
time. 

"The rate of nursing home 
use stabilized between 
1973-74 and 1977, following 
a decade of extremely rapid 
growth. The earlier upsurge 
in use resulted when eligibili- 
ty requirements for public 
payments for nursing home 
care were liberalized in the 
mid-1 960's and then again in 
1972, particularly under the 
Medicaid program. Use of 
nursing homes also increased 
as elderly patients were 
shifted from long term 
psychiatric institutions to nurs- 
ing homes. This shift 
occurred because States 
could receive Federal match- 
ing funds under Medicaid for 
nursing home care but not 
for care provided in long 
term psychiatric hospitals. 
Prior to Medicaid, eligibility 
for public payments was so 
limited that many potential 
nursing home users were 
unable to obtain such care." 
(13, p. 38) 



237 



As might be expected, 
females, who are longer 
lived, used nursing homes at 
a higher rate than did males, 
and the female-to-male ratio 
increased systematically and 
substantially over the 4 
reported years: 2.15 (1963), 
2.48 (1969), 2.62 (1973-74), 
and 2.83 (1977). The popula- 
tion in nursing homes has 
been predominately white 
(over 90 percent). The 
percentage of all other races 
(Hispanics are counted 
among the white) residing in 
nursing homes has shown a 
systematic increase, at first 
small, and then increasing 
suddenly in the last 3 years 
of the reported period. The 
percentage of all other races 
in the 4 years reported was 
3.1, 3.7, 4.3, and 5.9. 

Over the 14-year period 
studied, the number of 
elderly residents in nursing 
homes increased by 88 per- 
cent. In 1977, 1.5 percent of 
those 65 to 74 years of age 
were in nursing homes, but 
6.8 percent of those 75 to 84 
years of age and 21.6 per- 
cent of those 85 years of age 
and older were in nursing 
homes, reflecting the greater 
use of these facilities with in- 
creasing age. 



238 



Table 1 

Physician visits, according to source or place of care and selected patient characteristics: United States, 1964, 1975, and 1980. 



Physician visits 1 



Selected characteristic 



All sources 
or places 1 



1964 1975 1980 

Number per person 

Total 3 ' 4 ' 5 4.6 5.0 4.7 

Age 

Under 17 years 3.7 4.2 4.4 

17-44 years 4.6 5.0 4.4 

45-64 years 5.0 5.6 5.1 

65 years and over 6.7 6.6 6.4 

Sex 3 

Male 4.0 4.4 4.1 

Female 5.1 5.6 5.3 

Race 36 

White 4.7 5.1 4.8 

Black 7 3.6 4.9 4.6 

Family income 3 ' 8 

Less than $7,000 3.9 5.9 5.5 

$7,000-39,999 4.2 5.2 4.4 

$10,000-$1 4,999 4.7 5.0 4.9 

$15,000-$24,999 4.8 4.9 4.7 

$25,000 or more 5.2 5.0 4.6 

Geographic region 3 

Northeast 4.5 5.3 4.7 

North Central 4.4 4.7 4.7 

South 4.3 4.6 4.6 

West 5.5 5.9 4.9 

Location of residence 3 

Within SMSA 4.8 5.3 4.9 

Outside SMSA 4.1 4.4 4.4 



Doctor's office or 
clinic or group 
practice 



Hospital outpatient 
department 2 



Telephone 



1964 1975 1980 1964 1975 1980 1964 1975 1980 



69.7 67.1 



62.2 
73.8 
76.8 
64.2 



69.9 
69.5 



71.0 
56.2 



62.0 
65.2 
69.5 
71.5 
72.9 



67.2 
72.2 
68.9 
70.9 



68.2 
72.9 



62.2 
66.1 
72.6 
76.2 



65.4 
68.1 



68.1 
58.5 



60.1 
64.0 
64.5 
68.6 
70.2 



63.4 
68.4 
67.7 
69.1 



65.6 
71.0 



67.1 



63.1 
66.4 
70.7 
75.7 



65.7 
68.0 



68.4 
57.0 



58.8 
61.7 
66.1 
70.5 
70.6 



63.0 
69.4 
66.8 
69.2 



66.1 
69.5 



Percent of visits 
12.2 13.2 13.1 



13.7 
13.0 
10.0 
8.5 



13.2 
11.4 



10.2 
32.7 



25.9 
22.3 
11.1 
7.4 
6.7 



10.1 
10.6 
14.0 
14.3 



12.3 
11.9 



14.6 
13.7 
12.1 
9.0 



15.0 
12.0 



11.9 
23.5 



19.7 
17.9 
16.1 
12.4 
8.9 



15.5 
11.7 
13.1 
12.7 



14.0 
1 1.4 



13.1 
14.2 
12.3 
10.2 



15.4 
11.6 



11.3 

26.2 



20.7 
16.0 
14.0 
10.8 
9.0 



15.7 
10.7 
13.2 
13.0 



13.8 
11.3 



11.0 13.1 



18.3 
8.1 
6.1 
8.2 



9.3 
12.2 



11.7 
4.2 



4.8 
6.6 
11.7 
13.8 
12.9 



11.5 
11.7 
11.0 
9.5 



12.1 



17.7 
12.2 
9.7 
8.5 



11.5 
14.1 



14.0 

7.0 



10.0 
9.8 
12.9 
13.7 
15.7 



14.0 
14.7 
11.2 
12.9 



13.6 
11.9 



12.8 



17.3 
11.3 
10.2 
8.9 



11.3 
13.8 



13.8 

5.5 



9.1 
13.8 
13.2 
12.9 
14.5 



13.6 
14.9 
11.3 
11.4 



13.1 
12.0 



1 Does not add to 100 percent because it does not Include all sources or places (e.g., house calls), 
includes hospital outpatient clinic or emergency room. 

3 Age adjusted by the direct method to the 1970 civilian noninstitutionalized population, using 4 age intervals, 
includes all other races not shown separately, 
includes unknown family income. 

6 ln 1964 and 1975. the racial classification of persons in the National Health Interview Survey was determined by interviewer observation. In 1980, race was determined by 
asking the household respondent. 
7 1964 data are for all other races. 

6 Family income categories for 1980. Adjusting for inflation, corresponding income categories in 1964 were: less than $2,000; $2,000-$3,999; $4,000-56,999; $7.000-S9.999; 
and $10,000 or more; and, in 1975 were: less than $5,000; $5,000-$6,999; $7.000-$9,999; $10,000-$1 4,999; and $15,000 or more. 

Source: National Center for Health Statistics: Data from the National Health Interview Survey, Division of Health Interview Statistics. In Health United States, 1982. DHHS Publica- 
tion No. (PHS) 83-1232. Hyattsville, MD, 1982. 



239 



Table 2 

Percent distribution of physician visits for diagnosis and treatment, according to selected characteristics: 
United States, selected years. 



Characteristic 




1971 


1975 


1980 








Percent distribution 




All persons 1 




81.4 


84.9 


84.4 




Sex 








Male 




83.9 


87.0 


87.6 


Female 




79.6 


83.4 


82.1 












Under 5 years 




74.8 


79.6 


77.8 


5-14 years 




84.2 


86.4 


86.9 


15-24 years 




72.6 


77.5 


75.5 


25-34 years 




75.0 


80.4 


77.7 


35-44 years 




85.0 


86.7 


87.3 


45-54 years 




87.1 


88.8 


92.2 


55-64 years 




83.0 


91.5 


91.4 


65-74 years 




88.9 


91.1 


91.2 


75 years and over 


87.9 


91.3 


90.2 




Race 2 








White 




81.3 


84.9 


84.7 


Black 




82.6 


85.1 


82.7 




Family income 








Poor 




85.5 


88.8 


85.5 


Nonpoor 




80.1 


84.0 


83.7 




Activity limitation 








Unable to carry on major activity 3 


94.6 


94.6 


95.8 


Limited in amount or kind of major activity 3 


93.0 


94.1 


93.9 


Limited but not in major activity 


88.8 


91.2 


92.6 


Not limited in activity 


77.6 


81.3 


80.3 




Geographic region 








Northeast 




82.3 


85.2 


83.4 


North Central 




79.7 


84.7 


84.7 


South 




82.4 


83.8 


85.1 


West 




81.0 


86 3 


83 9 



includes races other than White or Black, and unknown family Income. 
2 ln 1971, Black race includes "All Other" races. 

3 Ma|or activity refers to ability to work, keep house, or engage in school or preschool activities 

Source Compiled and abstracted by CHESS from 1) National Center for Health Statistics: Physician visits, volume and interval 
since last visit: United States, 1971. DHEW publication no. (HRA) 75-1524. Series 10, Data from the National Health Survey, no. 
97, U S Government Printing Office, Washington, DC, March 1975. 2) National Center for Health Statistics: Physician visits, volume 
and interval since last visit: United States, 1975. DHEW publication no. (PHS) 79-1556. Series 10, Data from the National Health 
Survey, no. 128 US Government Printing Office, Washington, DC, April 1979. 3) National Center for Health Statistics: Physician 
visits, volume and interval since last visit. United States, 1980. DHHS publication no. (DHHS) 83-1572. Series 10. Data from the 
National Health Survey; no. 144 U S Government Printing Office. Washington, DC, June 1983. 



240 



Table 3 

Office visits to physicians, according to physician specialty and selected patient characteristics: United States, 1975 and 1980. 

Specialty 

General 

and Obstetrics 
Selected All family Internal and General 



characteristic 


specialties 1 


practice 


medicine 


gynecology 


Pediatrics 


surgery 


1 975 


1980 


1 9 / 1 1 


1980 


1975 


1980 


1975 


1980 


1975 


1980 


1975 


1 980 














Visits per person 












Total 2 


2.69 


2.63 


1.11 


0.86 


0.28 


0.30 


0.22 


0.23 


0.25 


0.37 


0.19 


0.13 


Aae 


























Under 15 years 


1.89 


2.21 


0.65 


0.54 


0.04 


0.03 


0.02 


0.01 


0.83 


1.20 


0.05 


0.05 


15-44 years 


2.52 


2.36 


1.03 


0.81 


0.20 


0.20 


0.44 


0.48 


0.03 


0.04 


0.19 


0.12 


45-64 years 


3.43 


2.99 


1.52 


1.08 


0.56 


0.58 


0.13 


0.12 


0.00 


0.00 


0.33 


0.20 


65 years and over . . . 


4.26 


4.22 


1.94 


1.56 


0.82 


0.95 


0.05 


0.06 


0.00 


0.00 


0.34 


0.22 


Sex2 


























Male 


2.25 


2.25 


0.95 


0.73 


0.25 


0.28 


0.00 


0.00 


0.26 


0.39 


0.16 


0.12 


Female 


3.14 


2.98 


1.25 


0.98 


0.32 


0.33 


0.42 


0.44 


0.25 


0.34 


0.22 


0.13 


Race 23 


























White 


2.76 


2.73 


1.12 


0.89 


0.29 


0.31 


0.22 


0.23 


0.27 


0.39 


0.20 


0.13 


All other 


2 25 


2.03 


1.05 


0.70 


0.23 


0.24 


0.23 


0.23 


0.17 


0 25 


0.13 


0.08 



'Includes other specialties not shown separately. 

2 Age adjusted by the direct method to the 1970 civilian noninstitutionalized population, using 4 age intervals. 

3 A change in the coding procedure for racial categories in 1980 may be partially responsible for the drop in office visits for the 

all other racial group 

Note: Rates are based on the civilian noninstitutionalized population, excluding Alaska and Hawaii. 

Source: National Center for Health Statistics: Data from the National Ambulatory Medical Care Survey, Division of Health Care Statistics. 
In Health United States, 1982. DHHS Publication No. (PHS) 83-1232. Hyattsville. MD, 1982. 



241 



Table 4 

Percent distribution of persons with five or more physician visits per year, according to selected 
characteristics: United States, selected years. 



Characteristic 


1967 


1971 


1975 


1980 






Percent distribution 




All persons 1 


19.7 


22.0 


22.4 


20.8 


Sex 










Male 


15.7 


17.7 


17.9 


16.7 


Female 


23.4 


26.2 


26.2 


24.7 


Ann 

«ye 










Under 5 years 


27.3 


32.8 


32.1 


31.5 


5-14 years 


10.1 


1 1 .8 


12.2 


12.3 


15-24 years 


18.4 


19.9 


19.2 


17.2 


25-34 years 


22.1 


23.7 


23.0 


21.2 


35-44 years 


18.6 


19.6 


20.1 


17.7 


a t— r~ a 

45-54 years 


20.0 


on a 

ctLA 




19.5 


55-64 years 


22.5 


26.4 


27.7 


25.1 


65-74 years 


28.6 


31.6 


32.6 


30.8 


75+ years 


30.1 


34.9 


37.1 


33.6 


Family income 










Poor 


21.4 


ZD. 1 


07 Q 

iLi .y 


25.4 


Nonpoor 


19.6 


21.3 


21.5 


19.4 


Race^ 










White 


20.4 


22.5 


22.4 


20.9 


Nonwhite 


14.8 


18.9 


21.7 


20.5 


Aptivitw limit^tinn 

rALAI VILV MIIIILC1LILJM 










Unable to carry on major activity 3 


46.8 


53.0 


56.8 


53.1 


Limited in amount or kind of major activity 3 


43.0 


48.3 


48.2 


46.9 


Limited, but not in major activity 3 


40.0 


36.8 


36.2 


34.4 


Not limited in activity 


25.3 


18.5 


18.1 


16.6 


Geographic region 










Northeast 


20.9 


22.8 


23.3 


21.4 


North Central 


19.5 


20.9 


21.7 


20.7 


South 


11.5 


21.1 


21.2 


20.0 


West 


22.1 


24.5 


24.1 


21.5 



'Includes races other than White or Black, and unknown family income 
2 ln 1967 and 1971, Black race includes "All Other" races. 

3 Major activity refers to ability to work, keep house, or engage in school or preschool activities. 

Source: Compiled and abstracted by CHESS from 1) National Center for Health Statistics: Volume of physician visits. United States, 
July 1966-June 1967 DHEW publication no. (HRA) 76-1299. Series 10, Data from the National Health Survey; no 49 U. S. Govern- 
ment Printing Office. Washington, DC, November, 1968. 2) National Center for Health Statistics: Physician visits, volume and inter- 
val since last visit: United States, 1971 DHEW publication no. (PHS) 75-1524. Series 10, Data from the National Health Survey; 
no 97 U S. Government Printing Office, Washington, DC. March, 1975. 3) National Center for Health Statistics: Physician visits, 
volume and interval since last visit: United States, 1975 DHEW publication no. (PHS) 79-1556 Series 10, Data from the National 
Health Survey; no. 128 U.S. Government Printing Office, Washington, DC, April, 1979 4) National Center for Health Statistics: 
Physician visits, volume and interval since last visit: United States, 1980. DHHS publication no. (DHHS) 83-1572. Series 10, Data 
from the National Health Survey; no 144 U S. Government Printing Office, Washington, DC June, 1983. 



242 



Table 5 

Percent of discharges from short-stay hospitals, according to selected characteristics: United States, 
1975 and 1980. 

Discharges 1 

Selected characteristic 

ly/o nyou 
Percent distribution 

Total 2.3.4 -12.4 12.0 

Age 

Under 17 years 6.9 6.2 

17-44 years 11.3 10.5 

45-64 years 17.5 16.6 

65 years and over 25.0 27.7 

Sex2 

Male 11.7 11.9 

Female 13.1 12.1 

Race 2 ' 5 

White 12.4 12.0 

Black 12.9 13.0 

Family income 2,6 

Less than $7,000 16.1 15.7 

$7,000-$9,999 14.7 14.2 

$10,000-$14,999 12.9 12.0 

$15,000-524.999 12.3 11.1 

$25,000 or more 10.6 10.2 

Geographic area 2 

Northeast 11.1 10.5 

North Central 12.8 12.6 

South 13.6 13.9 

West 1 1.7 9.6 

Location of residence 2 

Within SMSA 11.9 11.0 

Outside SMSA 13.6 14.1 

'Excluding deliveries. 

2 Age adjusted by the direct method to the 1970 civilian noninstitutionalized population, using 4 age intervals, 
includes all other races not shown separately. 
"Includes unknown family income. 

5 ln 1975, the racial classification of persons in the National Health Interview Survey was determined by interviewer observation. 
In 1980. race was determined by asking the household respondent 

6 Family income categories for 1980. Adjusting for inflation, corresponding income categories in 1975 were: less than $5,000: 
$5,000-$6,999; $7,000-59,999; $10,000-$1 4,999; and $15,000 or more. 

Source: Compiled and abstracted by CHESS from National Center for Health Statistics, Division of Health Interview Statistics: Data 
from the National Health Interview Survey. In Health United States, 1982. DHHS Publication No. (PHS) 83-1232. Hyattsville, MD, 1982. 



243 



Table 6 

Average length of stay in short-stay hospitals, according to selected characteristics: United States, 1975 
and 1980. 

(Data are based on household interviews of a sample of the civilian nomnstitutionalized population.) 



Selected characteristic 


Average 
1975 


length of stay 1 
1980 




Number of days 


Total 2 3 4 


7.5 


7.1 


Age 






Under 1 7 years 


5.6 


5.2 


1 7-44 years 


fi ft 


fi ft 


45-64 years 


9 7 


9.4 


65 years and over 


1 2 0 


10.0 


Sex2 






Male 


7.9 


7.9 


Female 


"7 O 

7.2 


b.b 


nace c " j 






White 


1 -d 


b.y 


Black 


O Q 

y.o 


y.^ 


Family income 2,6 






Less than $7,000 


9 6 


8.4 


S7.000 $9,999 


7.6 


8.2 


$10, 000-$1 4,999 


7.7 


6.9 


$15 000-$24 999 


7.0 


6.5 


$25,000 or more 


6.6 


6.0 


Geographic area 2 






Northeast 


9.2 


7.8 


North Central 


7.5 


7.0 


South 


7.0 


7.1 


West 


6.2 


6.4 


Location of residence 2 






Within SMSA 


7.8 


7.5 


Outside SMSA 


6.8 


6.7 



'Excluding deliveries 

2 Age ad|usted by the direct method to the 1970 civilian nomnstitutionalized population, using 4 age intervals, 
includes all other races not shown separately. 
"Includes unknown family income 

5 ln 1975, the racial classification of persons in the National Health Interview Survey was determined by interviewer observation 
In 1980, race was determined by asking the household respondent 

6 Family income categories for 1980. Adjusting for inflation, corresponding income categories in 1975 were: less than $5,000: 
$5,000-$6.999. $7,000-$9,999; $10,000-$1 4,999; and $15,000 or more. 

Source: Compiled and abstracted by CHESS from National Center for Health Statistics, Division of Health Interview Statistics: Data 
from the National Health Interview Survey In Health United States, 1982. DHHS Publication No. (PHS) 83-1232 Hyattsville, MD. 1982. 



244 



Table 7 

Number of patients discharged from short-stay hospitals, with procedures, by age, sex, and race of 
patient and geographic region of hospital: United States, 1975 and 1980. 

(Discharges from non-Federal short-stay hospitals. Excludes newborn infants.) 

Patients with % patients with 



Characteristic All discharged patients surgical procedures surgical procedures 





1975 


1980 


1975 


1980 


1975 


1980 






Number in thousands 




Percent 


All patients 


34,042 


37,832 


14,189 


17,005 


41.7 


44.9 


Age 














Under 15 years 


3,826 


3,672 


1,689 


1,385 


44.2 


37.7 


1 5-44 years 


14,171 


15,635 


6,557 


8,846 


46.3 


56.6 


45-64 years 


8,391 


8,660 


3,579 


3,575 


42.7 


41.3 


65 years and over . . . 


7,654 


9,864 


2,363 


3,198 


30.9 


32.4 


Sex 














Male 


13,519 


15,145 


5,401 


5,975 


40.0 


39.4 


Female 


20,523 


22,686 


8,787 


11,031 


42.3 


48.6 


Race 














White 


25,715 


28,484 


10,705 


12,828 


41.0 


45.0 


All other 


3,798 


4,879 


1,482 


2,105 


39.0 


43.1 


Race not stated 


4,529 


4,469 


2,002 


2,072 


44.2 


46.4 


Geographic region 














Northeast 


7,351 


7,868 


3,314 


3,677 


45.1 


46.7 


North Central 


10,677 


10,378 


4,494 


5,022 


42.1 


46.2 


South 


10,562 


12,983 


3,902 


5,304 


37.0 


40.4 


West 


5,454 


6,103 


2,479 


3,003 


45.4 


49.2 



Source: Compiled and abstracted by CHESS from 1) National Center for Health Statistics: Utilization of short-stay hospitals: annual 
summary for the United States, 1975. DHEW publication no. (HRA) 77-1782 Series 13, Data from the National Health Survey; no. 
31 U.S. Government Printing Office, Washington, DC, April 1977. 2) National Center for Health Statistics: Utilization of short-stay 
hospitals, annual summary for the United States, 1980. DHHS publication no (PHS) 82-1725. Series 13, Data from the National 
Health Survey; no 64. U.S. Government Printing Office, Washington, DC, March 1982. 



245 



Table 8 

Nursing home and personal care home residents 65 years of age and over and number per 1,000 population, according to sex and 

race: United States, 1963, 1969, 1973-74 and 1977. 

(Data are based on a sample of nursing homes.) 



Year and age 


Total 


Sex 


Race 


Total 


Sex 




Race 




Male 


Female 


White 1 


All Other 


Female 


Male 


White 1 All Other 








Number of residents 






Number per 1,000 population 




1963 






















65 years and over . . 


445,600 


141 ,000 


JU4,bUU 


4o1 , / UU 


13,800 


25.4 


1 o.l 


ol .1 


^b.b 


10.3 


65-74 years 


89,600 


35,100 


54,500 


84,400 


5,200 


7.9 


6.8 


8.8 


8.1 


5.9 


75-84 years 


207,200 


65,200 


142,000 


202,000 


5,300 


39.6 


29.1 


47.5 


41.7 


13.8 


85 years and over 


I 4o, / UU 


40,700 


1 dr nnn 

I uo,uuu 


1 4R 400 


3,300 


A AO A 


1 p, 

I UJ . vj 


1 7^ 1 


1S7 7 


41.8 


1969 






















65 years and over . . 


722,200 


207,100 


r- -i r onn 
bl b,^u(J 


cnc nnn 


27,300 


37.1 


or n 


4b. 1 


oo o 
Jo. 8 


17.6 


65-74 years 


138,500 


52,200 


86,300 


129,500 


9,000 


11.6 


9.9 


12.9 


11.7 


9.6 


75-84 years 


321,800 


90,800 


231,100 


310,900 


10,900 


51.7 


36.0 


62.3 


54.1 


22.9 


85 years and over 


oci o.nn 

zdi ,yuu 


64,100 


1 97,800 


r\r~ a r~ r\r\ 

254,500 


7,400 




1 30.8 


247.6 


221 .9 


52.4 


1973-74 2 






















65 years and over . . 


961,500 


iDD, / UU 


695,800 


920,600 


a n Qnn 
4u,yuu 


45.1 


30.2 


55.5 


47.3 


21.9 


65-74 years 


163,100 


65,100 


98,100 


150,100 


13,000 


12.3 


11.3 


13.1 


12.5 


10.6 


75-84 years 


384,900 


102,300 


282,600 


369,700 


15,200 


59.4 


40.8 


71.1 


61.9 


30.1 


85 years and over 


413,600 


98,300 


315,300 


400,800 


12,800 


253.7 


180.4 


290.6 


269.0 


91.4 


19773 






















65 years and over . . 


1,126,000 


294,000 


832,000 


1,059,900 


66,100 


47.9 


30.7 


59.7 


49.7 


30.4 


65-74 years 


211,400 


80,200 


131,200 


187,500 


23,800 


14.5 


12.7 


15.9 


14.2 


16.8 


75-84 years 


464,700 


122,100 


342,600 


443,200 


21,500 


68.0 


47.4 


80.6 


70.6 


38.6 


85 years and over 


449,900 


91,700 


358,200 


429,100 


20,800 


216.4 


140.0 


251.5 


229.0 


102.0 



1 Includes Hispanics. 

2 Excludes residents in personal care homes, 
includes residents in domiciliary care homes. 

Source: National Center for Health Statistics: Characteristics of residents in institutions for the aged and chronically ill. United States, 
April-June 1963, by G.S. Wunderlich, Vital and Health Statistics, Series 12-No. 2. DHEW Pub. No. (PHS) 1000. Public Health Service. 
U.S. Government Printing Office, Washington, DC, Sept. 1965: Measures of chronic illness among residents of nursing and personal 
care homes. United States, by D.K. Ingram, Vital and Health Statistics, Series 12-No. 24, DHEW Pub No. (HRA) 74-1709. Health 
Resources Administration, U.S. Government Printing Office, Washington, DC, May 1974. Unpublished data from the National 
Nursing Home Survey, in Health United States, 1982. DHHS Publication No. (PHS) 83-1232, Hyattsville, MD 1982. 



246 



References 

1. Wilson, R.W., and White, 
E.L.: "Changes in Morbidity, 
Disability, and Utilization Dif- 
ferentials between the Poor 
and the Nonpoor: Data from 
the Health Interview Survey: 
1964 and 1973." Reprinted 
from Medical Care, August 
1977, Vol. XV, No. 8, U.S.A. 

2. Collins, J.G.: Physician 
visits, volume and interval 
since last visit, United States, 
1980. Vital and Health 
Statistics. Series 10, No. 144. 
DHHS Pub. No. (PHS) 
83-1572. Public Health Serv- 
ice. Washington, DC, June 
1983. 

3. Kopstein, A.: "Utilization 
of Health Resources." In 
Health, United States, 1979. 
HHEW Pub. No. (PHS) 
808-1232. Hyattsville, MD, 
1979. 

4. Jack, S.S.: Current 
Estimates from the National 
Health Interview Survey: 
United States, 1980. Vital and 
Health Statistics. Series 10, 
No. 139. DHHS Pub. No. 
(PHS) 82-1567. Washington, 
DC, 1981. 

5. Collins, J.G.: Physician 
visits, volume and interval 
since last visit, United States, 
1980. Vital and Health 
Statistics. Series 10, No. 144. 
DHHS Pub. No. (PHS) 
83-1572. Public Health Serv- 
ice. Washington, DC, June 
1983. 

6. Madans, J., and Klein- 
man, J.: "Use of Ambulatory 
Care by the Poor and Non- 
poor." In Health, United 
States, 1980. DHHS Pub. No. 
(PHS) 81-1232. Hyattsville, 
MD, 1980. 

7. U.S. Bureau of the Cen- 
sus: Statistical Abstract of the 
United States: 1982-83 (103d 
edition). Washington, DC, 
1982. 

8. Madans, J., and Klein- 
man, J.: "Use of Ambulatory 
Care by the Poor and Non- 
poor." In Health, United 
States, 1980. DHHS Pub. No. 
(PHS) 81-1232. Hyattsville, 



MD, 1980. 

9. Haupt, B.J.: Utilization of 
Short-Stay Hospitals: Annual 
Summary. Vital and Health 
Statistics. Series 13, No. 64. 
DHHS Pub. No. (PHS) 
82-1725. Public Health Ser- 
vice. Washington, DC, 1982. 

10. Kopstein, A.: "Utilization 
of Health Resources." In 
Health, United States, 1979. 
DHEW Pub. No. (PHS) 
808-1232. Hyattsville, MD, 
1979. 

1 1 . Bureau of the Census, 
1980 Census of Population: 
In Statistical Abstract of the 
United States: 1982-83 (103d 
edition). Washington, DC, 
1982. 

12. Palmore, E.: "Total 
Chance of Institutionalization 
among the Aged." The 
Gerontologist. 1976. 

13. Kopstein, A., Machlin, S., 
Feldman, J., and Kleinman, 
J.: "How Is Nursing Home 
Use Changing?" In Health in 
the United States Chartbook. 
DHEW Pub. No. (PHS) 
80-1233. Washington, DC, 
1980. 

14. Aday, L.A., Anderson, 
R., and Fleming, G.: Health 
Care in the U.S., Equitable 
for Whom? Beverly Hills, CA, 
1980. 

15. White, K.L., Anderson, 
D.O., Kalino, E., Kleczkowski, 
B.M., Puvola, T., and 
Vukmanovic, C: Health Serv- 
ices: Concepts and Informa- 
tion for National Planning and 
Management. 

16. Haupt, B.J.: Utilization of 
Short-Stay Hospitals: Annual 
Summary. Vital and Health 
Statistics. Series 13, No. 64. 
DHHS Pub. No. (PHS) 
82-1725. Public Health Serv- 
ice. Washington, DC, 1982. 



List of Tables 

1 . Physician visits, according 
to source or place of care 
and selected patient 
characteristics: United States, 
1964, 1975, and 1980. 

2. Percent distribution of 
physician visits for diagnosis 
and treatment, according to 
selected characteristics: 
United States, selected years. 

3. Office visits to physicians, 
according to physician 
specialty and selected patient 
characteristics: United States, 
1975 and 1980. 

4. Percent distribution of per- 
sons with five or more physi- 
cian visits per year, accord- 
ing to selected 
characteristics: United States, 
selected years. 

5. Percent of discharges 
from short-stay hospitals, ac- 
cording to selected 
characteristics: United States, 
1975 and 1980. 

6. Average length of stay in 
short-stay hospitals, accord- 
ing to selected 

characteristics: United States, 
1975 and 1980. 

7. Number of patients 
discharged from short-stay 
hospitals, with procedures, 
by age, sex, and race of pa- 
tient and geographic region 
of hospital: United States, 
1975 and 1980. 

8. Nursing home and per- 
sonal care home residents 65 
years of age and over and 
number per 1,000 popula- 
tion, according to sex and 
race: United States, 1963, 
1969, 1973-74, and 1977. 



247 



248 



Chapter XI 



Financial Expenditures 
for Health Services 



Table of Contents 



Overview 251 

A. Introduction 251 

B. Health Insurance Coverage 253 

C. Out-of-Pocket Expenses 253 

D. Federal Health Expenditures— The Aged 254 

E. Federal and State Health Expenditures— The 
Poor 257 

F. Federal and State Health Expenditures— The 
Young 258 

Tables 259 
References 262 
List of Tables 263 
List of Figures 263 



250 



Chapter XI 



Financial Expenditures for 
Health Services 



Overview 

This chapter assesses the 
degree to which access to 
health care, and thus health 
status, is affected by the 
financing of health care serv- 
ices. It explores two aspects 
of health care financing; (a) 
the degree to which health 
insurance coverage differs 
among racial/ethnic groups; 
and (b) the degree to which 
expenditures for health care 
vary between the groups of 
concern and the rest of the 
population. 

Personal health care ex- 
penditures in the United 
States for 1960 were $26.9 
billion. By 1980, this figure 
had risen to $249.0 billion, 
nearly a tenfold increase. 
Many factors caused this 
rapid rise in health care ex- 
penditures. The three main 
factors, in order of impor- 
tance, were: (a) increases in 
the price of health care serv- 
ices (mainly due to inflation); 
(b) increases in service inten- 
sity and quality; and (c) in- 
creases in utilization of health 
services. Although inflation 
was the major factor in the 
rise of health care expen- 
ditures, other factors were 
also at work: technological 
developments that made 
health care delivery much 
more capital intensive (in- 
cluding a number of extreme- 
ly expensive devices); in- 
creases in third-party 
payments for health care ex- 
penses, which resulted in in- 
creased utilization; the rise in 
population; the rise in 
malpractice costs; and the 
accompanying increases in 
the frequency and number of 
diagnostic tests ordered. 

Unless protected by 
private health insurance 
coverage and government 
programs, poor and near 



poor individuals are the 
hardest hit by rising medical 
costs. Even with existing 
coverages, nearly all of the 
individuals with medical ex- 
penses above 1 5 percent of 
their family income were 
those who had family in- 
comes below 200 percent of 
the poverty level. 

As health costs escalated, 
the percentage of health care 
charges paid out of pocket 
declined. In 1950, two-thirds 
of personal health care 
payments were made by the 
patient. By 1975, two-thirds 
of personal health care 
payments were made by 
third parties. This expansion 
of third-party payment has 
slowed, however, changing 
from 66.6 percent in 1975 to 
67.9 percent in 1981. 

Medicaid has gone a long 
way toward protecting the 
pocketbooks of the poor and 
the near poor. Persons with 
Medicaid had the lowest out- 
of-pocket expenses in 1980. 
This was true even though 
they had the highest mean 
per capita charges for health 
care. At the same time, 
Medicare has been effective 
in protecting the elderly. 
Elderly persons with a com- 
bination of Medicare and 
Medicaid (presumably the 
most needy) had the highest 
mean per capita total health 
charge and by far the lowest 
proportion of total charges 
paid out of pocket. The total 
elderly population has health 
care charges that are triple 
those of the nonelderly, but 
their out-of-pocket expenses 
were less than [twice] as 
high. 

Medicaid is financed joint- 
ly by Federal and State 
funds, but it is administered 
independently by each State 
within broad Federal 
guidelines. The guidelines 
leave the States with the flex- 



ibility to determine such mat- 
ters as eligibility, duration of 
coverage, and the methods 
and levels of reimbursement. 
As the Medicaid program is 
expanding and beginning to 
consume greater proportions 
of general operating funds of 
the various States, the States 
are beginning to devise pro- 
gram changes concerning 
eligibility, benefits, or reim- 
bursement approaches that 
will enable them to maintain 
fiscal stability as expenditures 
increase. 

In 1980, whites had higher 
mean per capita health care 
charges and higher out-of- 
pocket expenses than blacks. 
Among the elderly, whites 
spent $342 and blacks spent 
$186, on the average, for 
health care services. For the 
elderly who had Medicaid 
coverage, out-of-pocket ex- 
penditures were $266 for 
whites and $84 for blacks. 
Black children less than 6 
years of age had excep- 
tionally high Medicaid 
coverage. Forty-six percent 
were covered, compared with 
20 percent for the total 
under-6 population, and com- 
pared with 14 percent of the 
black 22-44 age group. 

Among Hispanics, 10.4 
percent of those 65 and over 
were covered by Medicaid in 
1980, compared with 14.5 
percent of the total elderly 
population. It is difficult to 
analyze this Hispanic age 
group's Medicaid statistics 
further, since they comprise 
such a small proportion of 
that ethnic group's numbers 
(4 percent) and because of 
their geographic concentra- 
tion, which places most of 
them in only a few State- 
based programs. 

One gap in Medicaid 
coverage, for children, was 
pointed out by Karen Davis. 



While the number of children 
living in poverty has increased 
in recent years, the number 
covered by Medicaid has 
decreased. Less than 40 per- 
cent of children living in 
poverty are covered. Davis 
attributes this to the fact that 
"thirty states do not offer 
Medicaid to children in intact 
families, even though their 
family income is low enough 
to qualify for welfare aid. 
Moreover, no state provides 
coverage for individuals up to 
the poverty level. In 29 
states, the income cutoff limit 
for Medicaid is less than 50 
percent of the federal poverty 
level." 

A. Introduction 

Total health care expen- 
ditures have been rising 
rapidly in the United States 
since 1960. The United 
States spent $26.9 billion for 
health care in 1960. By 
1980, it spent $249.0 billion, 
almost a tenfold increase. A 
15 percent increase in 1981, 
to $286.6 billion, brought the 
figure to over 10 times the 
1960 expenses (1) (see 
Figure 1). During this period, 
the Gross National Product 
increased less than sixfold. 

Because so many 
separate factors affect health 
care costs, the problem of 
rapidly rising health expen- 
ditures is extremely complex. 
Many factors are changing 
simultaneously. These 
changes include (a) the 
prices charged by health pro- 
viders, (b) the frequency and 
types of illness, (c) the con- 
tinued rise in total population, 
(d) the sex and age distribu- 
tion of the population, (e) in- 
creases in utilization of health 
services, (f) technological 
developments that make ex- 
pensive equipment available. 



251 



Figure 1 

National health expenditures: 1960 to 1981. 

Health mmm Private 

expenditures, total expenditures 
Billions of dollars 

1960 1965 1970 

300 



250 



1975 



Public 

expenditures 

1980 1981 



200 



150 



100 



20 



0 





Source: Chart prepared by U.S. Bureau of the Census. In U.S. Bureau of the Census, 
Statistical Abstract of the United States: 1982-83 (103d edition) Figure 4:1, p. 98. 
Washington, DC, 1982. Data Table Source: U.S. Health Care Financing Administra- 
tion, Health Care Financing Review, September, 1982. In U.S. Bureau of the Census, 
Statistical Abstract of the United States: 1982-83 (103d edition.) No. 149, p.101. 
Washington, DC, 1982. 



(g) increases in the number 
of diagnostic tests being 
ordered, (h) increases in 
third-party payments, (i) 
governmental attempts at 
cost containment, and (j) the 
various responses by the 
health care providers to such 
changes. 

Inflation has also been a 
major contributor to increased 
health care costs, but it has 
not accounted for all of the 
rise. Between 1970 and 
1979, for example, the Con- 
sumer Price Index rose by 87 
percent, while the medical 
care component of that index 
rose by 100 percent, and the 
hospital room component of 
medical care rose by 155 
percent (2). Thus health care 
costs have been outpacing 
the rise in general consumer 
prices. Increases in expen- 
ditures over time can mean 
decreased health care ser- 
vices, because all of the fac- 
tors listed above affect the 
cost of health care. 

In addition, the last three 
decades have witnessed pro- 
found changes in who pays 
for health care. "In 1950, 
two-thirds of personal health 
care payments were made 
by the patient: by 1980, this 
proportion had declined to 
one-third." The share of ex- 
penditures for personal health 
care paid by Federal, State, 
and local governments rose 
from 22 to 40 percent be- 
tween 1965 and 1980 (3. p. 
81). Between 1950 and 
1966, the growth of private 
health insurance coverage 
resulted in a decline of the 
out-of-pocket portion to just 
over half of the total personal 
health care expenditures. 
Since 1968, with the in- 
auguration of Medicare and 
(soon after) Medicaid, the 
major shift has been to public 
agency payments, with the 
out-of-pocket share declining 
to one-third (4, p. 54). 

Neither the rise of private 
health insurance nor 



Medicare and Medicaid slow 
the rise in total health care 
expenditures nor were they 
intended to. Private health in- 
surance merely spreads the 
risk of larger health expen- 
ditures, and thus protects the 
individual family from the 
financial burden of sudden ill- 
ness. If anything, it adds a 
small amount to the total 
health care expenditures (to 
cover administrative costs). 
Medicare and Medicaid were 
intended to enhance access 
to health care for the 
medically underserved 
segments of the population. 
Thus, to the extent that this 
aim is achieved, more per- 
sons are being served, and 
expenditures continue to rise. 
Furthermore, as Weichert 
wrote: "The presence of 
third-party payment tends to 
blur the relationship between 
the amount and type of 
health care services 
consumed and their costs. In 
other words, the out-of- 
pocket cost of health care to 



the consumer, at the time of 
services, is reduced or 
eliminated— encouraging 
both provider and consumer 
to increase utilization, de- 
mand higher quality care, 
and thereby generate higher 
costs." (3, p. 81) 

Advances in medical 
technology have greatly 
altered the character of the 
health care product over the 
past few decades, but their 
effect on expenditures has 
been mixed. Each new 
technological innovation has 
its costs and benefits. If a 
new procedure, device, or 
vaccine can reduce the 
prevalence of some medical 
condition, the cost of its 
development and administra- 
tion could outweigh any sav- 
ing derived from reduced in- 
cidence. If it prolongs life, the 
new effect could be an in- 
crease, rather than a reduc- 
tion, in the frequency or 



duration of medical treatment. 
Organ transplant is an exam- 
ple of such a procedure. 
Renal dialysis is another. 
New, expensive diagnostic 
aids prompt interhospital 
competition to have the most 
modern facilities, even if 
those diagnostic aids are 
underutilized. 

The various direct at- 
tempts at medical cost con- 
tainment have had only 
limited success thus far. They 
have been successful 
enough, however, to en- 
courage other agencies to try 
to improve upon them. Some 
of the cost containment 
strategies that have been ap- 
plied are: 

■ Second opinion and 
prior approval programs. 

■ Comprehensive 
regional planning to 
reduce duplication of 
facilities. 

■ Need review programs 
to control hospital capital 
expansion. 

■ Economic incentives to 
induce more efficient use 
of resources. 

■ Health maintenance 
organizations to replace 
the traditional fee-for- 
service arrangement of 
health care delivery. 

The number of health 
maintenance organizations 
(HMO's) grew slowly until 
1970 and more rapidly since 
February 1971, when Presi- 
dent Nixon advocated HMO's 
in a message to Congress. 
Between 1929 and 1970, 
their number rose from 1 to 
30, with 3.1 million enrollees. 
By 1980, there were about 
235 prepaid plans, with an 
estimated 9.5 million 
enrollees. Despite this 
growth, HMO's still have a 
great potential for continued 
expansion. In 1980, 2.2 per- 
cent of those eligible for 
Medicare, and 1 .5 percent of 
those eligible for Medicaid, 
were enrolled in HMO's. The 
1976 amendments to the 
1973 HMO act permitted, 



252 



with limited exceptions, only 
qualified HMO's to contract 
with States to provide ap- 
propriate health services. This 
action has reduced the in- 
cidence of fraud, improper 
marketing and enrollment 
practices, and inadequate 
care provided by HMO's (5). 

A recent Vanderbilt 
University study (funded by 
the National Center for Health 
Services Research) claims 
that mandatory rate-setting is 
the most effective regulatory 
program for containing 
hospital costs. In the six 
States that have adopted this 
measure so far, hospital costs 
per day were an average of 
16 percent lower than 
hospital costs elsewhere, and 
costs per admission were 10 
percent less. These results 
were achieved by reducing 
payments to hospitals per 
day and per case, not by 
curbing admissions or length 
of stay (6). Cost curtailment 
efforts such as this are impor- 
tant to the disadvantaged 
because of their utilization 
patterns (i.e., the disadvan- 
taged have a higher fre- 
quency of use of health care 
services, and their out-of- 
pocket health expenses are a 
greater proportion of their 
family income). 

In view of the high cost of 
receiving health care in the 
United States, the financial 
impact of health care on 
segments of the population, 
particularly the disadvan- 
taged, may be excessive. To 
explore this further, we must 
examine the answers to the 
following questions: 

1. How do the per capita 
personal health care ex- 
penditures of the disad- 
vantaged compare with 
those of the rest of the 
population? 

2. What proportion of the 
health care dollar goes 
toward hospital care, 



physician care, etc., for 
the disadvantaged com- 
pared with the rest of the 
population? 

3. How do health in- 
surance coverage and the 
out-of-pocket costs of the 
disadvantaged compare 
with those of the rest of 
the population? 

4. How has public health 
spending reduced those 
financial barriers to health 
care experienced by the 
disadvantaged? 

As with problems ana- 
lyzed in the other chapters of 
this book, caution must be 
used in interpreting any dif- 
ferentials that are found. Dif- 
ferentials may mean that 
there are differences in need, 
consumption practices, ac- 
cess, geographic population 
distributions, uses of in- 
surance coverages, age 
distributions, or the types of 
services received. Where 
possible, available data from 
all sources will be used to 
determine which of these is 
the case. 

Additional caveats on the 
interpretation of the data 
presented are contained in 
Chapter I of this book. 
B. Health Insurance 

Coverage 
The proportion of personal 
health care expenditures 
covered by insurance has in- 
creased over time. In 1950, 
two-thirds of personal health 
care expenditures were paid 
by the individual recipients of 
the health care (3). By 1975, 
two-thirds of personal health 
care expenditures were being 
paid by third parties. Gradual 
growth since 1975 raised the 
proportion to 67.9 percent by 
1981 (see Table 1). 

In 1980, 13.4 percent of 
all persons and 12.8 percent 
of all families were known to 
have no health insurance (7). 
(These figures applied to the 
civilian noninstitutionalized 
population.) In 1977, 79.4 
percent of the civilian 



noninstitutionalized population 
were privately insured at least 
some time during the year. A 
substantial difference existed 
between whites on the one 
hand, and blacks and 
Hispanics on the other hand, 
in the proportion covered by 
private insurance (85 percent 
compared to roughly 60 per- 
cent). Among groups defined 
by income, only 41 percent 
of persons in the poor or 
near-poor families (1.25 
poverty line or less) were 
privately insured, compared 
with 87 percent of individuals 
from middle income families 
(8). 

Government expenditures 
for personal health care rose 
from $5.5 billion in 1960 to 
$102.9 billion in 1981, mainly 
due to the introduction of 
Medicare and Medicaid to 
protect the undercovered 
and underserved segments 
of the population. By 1981, 
26.2 million individuals were 
covered by Medicare, and 
19.0 million were covered by 
Medicaid, with 3.5 million 
covered by both. Medicare 
covered 23.5 million in- 
dividuals aged 65 and over, 
and Medicaid covered 16.0 
million individuals below the 
age of 65. During 1980, 
Medicare covered 15.5 per- 
cent of the white population, 
12.9 percent of the black 
population, and 7.2 percent 
of the Hispanic population. 
Of course, these percentages 
must be viewed in light of the 
proportions of the aged in 
each of the racial/ethnic 
groups (see Chapter II). 
Medicare covered 95.4 per- 
cent of the population aged 
65 and over. During 1980, 
Medicaid covered 6.2 per- 
cent of the white population, 
24.2 percent of the black 
population, and 16.2 percent 
of the Hispanic population. 
These percentages must be 
interpreted in light of the pro- 
portions of poor and near 



poor in each of the 
racial/ethnic groups (see 
Chapter II). Overall, Medicaid 
covered 39.1 percent of the 
population below the poverty 
line and 4.0 percent of the 
population above the poverty 
line (9). 

Below the poverty line, a 
significantly smaller percent- 
age (30.9) of the white 
population was covered by 
Medicaid than any other 
racial/ethnic group. Of the 
black poor, 65.1 percent 
were covered, and of the 
Hispanic poor, 46.6 percent 
were covered by Medicaid in 
1980. Among the near poor 
(101-150 percent of poverty 
line), 14.7 percent of whites, 
25.1 percent of blacks, and 
28.8 percent of Hispanics 
had Medicaid coverage in 
1980 (10). 

An interesting racial/ethnic 
difference in Medicaid enroll- 
ment was reported by 
O'Brien, Rodgers, and Baugh 
(10). They showed that 10.4 
percent of Hispanics who 
were 66 and over had 
Medicaid coverage in 1980, 
compared with 14.5 percent 
for the total aged population, 
and compared with 18.1 per- 
cent of the Hispanic 22 to 44 
age group. The black age 
group with the highest 
percentage of Medicaid 
coverage was the 6 to 21 
group. Forty-six percent of 
blacks in this age group were 
covered by Medicaid, com- 
pared with 32.7 percent for 
the total population, and 
compared with 15.9 percent 
of the black 22 to 44 age 
group (see Table 2). 
C. Out-of-Pocket Expenses 
For the individual health care 
recipient, the total amount 
spent on health care is not 
as important as the amount 
that comes out of his or her 
pocket. Those health care 
costs paid directly by the 



253 



Figure 2 

Mean per capita out-of-pocket expenses of the elderly, by poverty level, 1980. 



Poverty 
Level 



$400 



$300 



$200 



$100 



$0 



All Elder 
$327 


0-55% 


56-75% 


76-100% 


101-150% 


151-200% 


200% 


Total Po 
tion it>iy!: 


pula- 



























Source: Unpublished draft, Deliverable. No. 305F, Health Care Financing Administration, 
February 28, 1983. Howell, E.,Corder, L.,and Dobson, A.: Out-of-Pocket health expenses 
for Medicaid and other poor and near poor persons in 1980. 



consumer for health services 
for insurance premiums are 
referred to as out-of-pocket 
expenses. The data on out- 
of-pocket expenses have 
been derived from an 
analysis of the National 
Medical Care Utilization and 
Expenditure Survey (1 1). 

The mean per capita out- 
of-pocket expenses for all 
noninstitutionalized persons in 
the United States in 1980 
were $195. This represented 
27 percent of total charges 
($730). The elderly (65 and 
over) had charges that were 
nearly three times as high as 
the nonelderly ($604 versus 
$160), but their out-of-pocket 
expenses were less than 
twice as high ($327 versus 
$179). Thus, even though in- 
surance costs are included in 
out-of-pocket expenses, the 
elderly were paying 18.5 per- 
cent of their medical care 
cost. Figure 2 shows the out- 
of-pocket expenses of the 
elderly at different poverty 
levels. It is interesting to note 
that the elderly near-poor 
who were between 151 and 
200 percent of the poverty 
level paid more out-of-pocket 
medical expenses ($391 .85) 
than any other poverty level 
grouping. Table 3 shows 
that, although the mean per 
capita total charges were 
greatest for the elderly whose 
income was between 56 and 
75 percent of the poverty 
level ($2449.94), the elderly 
in the lowest poverty level 
(10-55 percent) paid the 
greatest proportion of the 
total charges out of their own 
pockets (24 percent). For the 
sake of equity, attention ap- 
parently needs to be focused 
on these two poverty levels 
(10-55 percent and 151-200 
percent of poverty level). 

There are large dif- 
ferences in out-of-pocket ex- 
penses between racial and 



ethnic groups. Whites had 
higher medical charges than 
blacks in 1980 ($755 versus 
$570) and paid a slightly 
higher percentage of those 
charges out of their own 
pockets (27 percent versus 
23 percent) (see Table 4). 
Non-Hispanics had higher 
medical charges than 
Hispanics in 1980 ($745 ver- 
sus $518) and their out-of- 
pocket expenses were also 
higher ($199 versus $150), 
but the percentage of 
charges paid out of pocket 
was about the same (27 per- 
cent versus 29 percent). 

Caution must be exercised 
in interpreting Hispanic 
Medicaid data. Medicaid 
eligibility requirements and 
benefits are based on State 
programs. Because of the 
limited geographic spread of 
Hispanics, this factor imparts 
particularly strong biases to 
these Medicaid data. One- 
third of all Hispanics live in 
one State (California); one- 
half live in two States (Califor- 



nia and Texas); two-thirds live 
in three States (California, 
Texas, and New York); and 
almost three-fourths live in 
four States (California, Texas, 
New York, and Florida). 

The higher charges and 
out-of-pocket expenses of the 
nonminority population were 
attributed to several factors 
by Howell, Corder, and 
Dooson (12). Nonminority 
people have higher utilization 
rates; they use more expen- 
sive health care providers; 
they use a different mix of 
services (for example, as 
noted in Chapter VIII, they 
use dental services much 
more often); and they have a 
high proportion of individuals 
in the age groups at or 
above 65. 

The mean per capita out- 
of-pocket expenses for all 
persons in 1977, as reported 
in the National Medical Care 
Expenditures Survey 
(NMCES) with analagous 
data for 1980 from the Na- 
tional Medical Care Utilization 
and Expenditure Survey 
(NMCUES), rose by 20 per- 



cent (from $163 to $195) 
while per capita health care 
expenditures were rising by 
70 percent. The above 
analysis refers to out-of- 
pocket expenses for all per- 
sons, including those who 
had no expense. Thus, it 
represents a measurement 
based on a population 
statistic. Another way of 
calculating out-of-pocket ex- 
penses is to include only 
those persons who had any 
expense. By doing so, an 
average expense for those 
persons can be arrived at. 
The NMCES mean out-of- 
pocket expense per person 
with expense was $215, 
compared with the NMCUES 
figure of $246, a 14 percent 
rise in 3 years (12). 
D. Federal Health 

Expenditures— The 

Aged 

In 1980, the average per 
capital health expenditures 
were 3.5 times greater for 
persons over 65 years of age 
than for those under 65 (13, 
pp. 158-159), even though 
they constituted only 15.4 
percent of the population. 
Thus this is the age group for 
whom Federal health 
insurance for the disad- 
vantaged is a must. "Title 
XVIII of the 1965 Social 
Security Amendments (P.L. 
89-97), authorized a federal 
program of health insurance 
for the aged known as 
Medicare. The explicit goal of 
Medicare was to reduce the 
financial barrier to access to 
health care for those age 65 
and over, aiding them in 
reaching needed services." 
(14, p. 274) "Since 1966, the 
private portion of health-care 
over-costs met by out-of- 
pocket payments, private 
health insurance, philan- 
thropy, and industry has 
been cut in half: from 70 per- 
cent in 1966 to 34 percent in 
1972 (15). Out-of-pocket 
payments made by the elder- 



254 



Figure 3 

Medicare reimbursement for physician services, by race, 1976. 
White 
Non-White 



Reimburse- 
ments (In 
Dollars) Per 
Person Served 



Persons 
Receiving 
Reimbursable 
Services Per 
1,000 Medicare 
Enrollees 



Reimburse- 
ments Per 
Person 
Enrolled 



Source: "Equal Treatment and Unequal Benefits: A Re-examination of the Use of 
Medicare Services by Race, 1967-1976," Ruther, M. and Dobson, A. In Health Care 
Financing Review, Winter, 1981. 



Ratio- White/Racial Minority 



Figure 4 

Medicare reimbursements for inpatient services, by race, 1976. 
White 

Racial Minority 



Reimburse- 
ments (In 
Dollars) Per 
Person Served 

Persons 
receiving 
Reimbursable 
Services Per 
1,000 Medicare 
Enrollees 

Reimburse- 
ments (In 
Dollars) Per 
Person Served 



Source: "Equal Treatment and Unequal Benefits: A Re-examination ot the Use of 
Medicare Services by Race, 1967-1976," Ruther, M. and Dobson, A. In Health Care 
Financing Review, Winter, 1981. 



ly declined sharply as a pro- 
portion of their personal, 
health-care costs, from 53.2 
percent in 1966 to 26.4 per- 
cent in 1968 and a low of 
25.5 by 1969." (16, pp. 
155-156) 

Has Medicare been effec- 
tive in reducing the financial 
impact of health care on the 
poor and racial minorities 
who are aged? From 
available data which relate 
reimbursement to race, it ap- 
pears that racial minorities 
received both lower and 
fewer Medicare reim- 
bursements for physician 
services than whites in 1976 
(see Figure 3). Of all Medicare 
enrollees with claims, the 
average reimbursement to 
whites for physician services 
was $299, compared with 
$263 for nonwhites (14 per- 
cent higher). Considering the 
total number of enrollees, 
both those who used and 
those who did not use the 
services, the average reim- 
bursement for whites was 32 
percent higher than for non- 
whites ($165.48 versus 
$125.36). Also, whites tended 
to use Medicare reimbursable 
physician services 16 percent 
more often than nonwhites 
(553 per 1,000 versus 476 
per 1,000). 

Although physician care 
and utilization favored whites 
in 1976, inpatient hospital 
care presented a different 
pattern (see Figure 4). 
Although whites again used 
the Medicare reimbursable 
services more (by 19 per- 
cent), nonwhites received a 
14 percent higher reimburse- 
ment per person served 
($2,379 for nonwhites and 
$2,085 for whites). The lower 
reimbursement rate of whites 
among those served is prob- 
ably explained by a shorter 
average length of hospital 
stay. As for reimbursement 
per person enrolled, the ratio 



of white to nonwhite expen- 
ditures was below 1.05. 

Medicare reimbursements 
to racial minorities for hospital 
outpatient services strongly 
favored non-whites in 1976 
(see Figure 5). Nonwhites 
used the Medicare reimburs- 
able outpatient services 16 
percent more often than 
whites (255 versus 194 per 
1,000). They received 51 per- 
cent more reimbursement per 
person served ($169 versus 



$112, and 75 percent more 
reimbursement per person 
enrolled in Medicare ($37.96 
versus $21.65). The higher 
outpatient charges for non- 
whites (per person served 
and per person enrolled) 
suggest that a different mix- 
ture or intensity of services is 
utilized by the two groups. If 
the higher out-patient 
charges to racial minorities 



mean more services per visit, 
then the racial differentials in 
outpatient department utiliza- 
tion follow those in inpatient 
utilization. That is, racial 
minorities may receive more 
services per visit to outpatient 
departments, just as they 
have more days per inpatient 
hospital stay compared to 
whites. 

Although it is interesting to 
examine racial/ethnic dif- 
ferences in expenditures for a 
given year, it is more impor- 
tant to examine trends in 
racial/ethnic expenditures. 
One of the better single 
measures of equity in the use 
of Medicare benefits is reim- 
bursement per enrollee, 
although using this measure 
in a comparative sense re- 
quires an assumption that a 
number of characteristics of 
the groups being compared 
are similar. This measure 
represents the average 
Medicare reimbursement 
paid to the population at risk. 
Ruther, Martin, and Dobson 
(17) have presented data 
(see Figure 6 and Table 5) 
that show strong improve- 
ment in the equity of 
Medicare reimbursement per 
enrollee between 1967 and 
1976. While this figure was 
rising by 306 percent for 
whites, it was rising by 425 
percent for nonwhites. The 
ratio of white to nonwhite 
reimbursements per enrollee 
decreased from 1.53 in 1967 
to 1.10 in 1976. Thus, 
although equality was not 
achieved by 1976, it was be- 
ing approached. An ex- 
trapolation of the trend shows 
that it is possible (but doubt- 
ful) that equity has been 
achieved in 1984. 

Reimbursement per per- 
son served shows a different 
trend (see Figure 7 and 
Table 5). When considering 
all Medicare services 
together, the ratio of whites 



255 



to non-whites for this statistic 
dropped gradually to 1.02 
between 1967 and 1971, fur- 
ther dropped to 0.97 by 
1974, and remained at this 
level for another 2 years. 
Thus it appears that 
racial/ethnic equity has been 
achieved on this dimension. 
However, it should be 
pointed out that the various 
component services of 
Medicare present different 
pictures as to equality. The 
ratio of white to nonwhite 
reimbursement per person 
served has been at or below 
1.00 since 1969 for every 
service except physician 
care. Reimbursement per 
person served for physicians' 
services has persistently 
shown higher average reim- 
bursements for whites in the 
1967-1976 period, and has 
exhibited a slow and irregular 
decline (17) (see Figure 8). 

Most of the Medicare data 
in this section came from an 
article by Ruther, Martin, and 
Dobson (17). The tentative 
conclusions stated in that arti- 
cle are very interesting. A 
few of the highlights are 
presented here: 

The Medicare program 
was partially responsible 
for the decreasing 
disparity by race among 
the aged for three 
reasons. First, the pro- 
gram increased access to 
medical care among aged 
persons by providing 
"free" hospital insurance 
for those entitled to social 
security. The program also 
offered voluntary sup- 
plementary medical in- 
surance (SMI) to the aged 
and Medicare shared the 
cost of the SMI premium. 
Many of those unable to 
afford the SMI premium 
obtained free coverage 
through the State buy-in 
program. Second, Medi- 
care reduced out-of- 
pocket medical costs by 
paying 80 percent of SMI 



Ratio- White/Racial Minority 



Figure 5 

Medicare reimbursements for hospital outpatient services, by race, 1976. 
White 

Racial Minority 



Reimburse- 
ment (In 
Dollars) Per 
Person Served 

Persons 
Receiving 
Reimbursable 
Services Per 
1,000 Medicare 
Enrollees 

Medicare 
Reimburse- 
ment (In 
Dollars) Per 
Person Served 



Source: "Equal Treatment and Unequal Benefits: A Re-examination of the Use of 
Medicare Services by Race, 1967-1976," Ruther, M. and Dobson, A. In Health Care 
Financing Review, Winter, 1981. 



Figure ® 

Use of all services by the aged, reimbursement per enrollee: ratio of white to 
non-white, 1967-1976. 

Ratio: White to 
Non-White Races 

















































:. ■ .. ■ .. 












msmmmmm 












Wmffl&m 



1.60 



1.50 



1.40 



1.30 



1.20 



1.10 



1.00 



1967 



1968 



1969 



1971 



1973 



1974 



1975 



1976 



Source: "Equal Treatment and Unequal Benefits: A Re-examination of the Use of 
Medicare Services by Race, 1967-1976," Ruther, M. and Dobson, A. In Health Care 
Financing Review, Winter, 1981. 



reasonable charges and a 
substantial part of HI 
(hospital Insurance) 
charges. Further, 
Medicaid eligibles entitled 
to Medicare do not have 
to pay their Medicare 
coinsurance and 



deductibles— these are 
paid by Medicaid. Third, 
institutional providers of 
medical care to Medicare 
enrollees are required to 
furnish services without 
discrimination. These three 



factors probably increased 
the use of medical care 
by Nonwhites more than 
by whites. The reason for 
this is: Nonwhites 
benefited more because a 
lower proportion of them 
probably had private 
health insurance than 
whites. The State buy-in 
program and probably the 
Medicaid program has 
disproportionate numbers 
of Nonwhite eligibles (17, 
p. 76). 

The authors go on to 
discuss factors other than 
Medicare that may have 
acted to decrease racial 
disparity, as well as factors 
that may act to perpetuate or 
increase disparity. Among the 
former class of factors, they 
list the civil rights movement, 
increased receptivity to 
medical care among non- 
whites, and a greater rate of 
acceleration in income 
among the nonwhite aged. 
Factors that may tend to in- 
crease white expenditures 
are the following: 

■ Because the white 
aged have higher in- 
comes, they are more 
likely to be able to afford 
private insurance to sup- 
plement Medicare. 
Therefore, their total health 
care expenditures may be 
greater. 

■ Because greater pro- 
portions of whites live in 
regions where prices and 
costs are higher, they are 
more likely to exceed the 
deductible of the SMI pro- 
gram of Medicare and to 
receive reimbursement. 

In addition to racial dis- 
parities, marked disparities in 
Medicare reimbursements 
among income groups were 
observed. Data on Medicare 
supplementary medical in- 
surance services, which in- 
clude physician services, 
hospital outpatient services, 
and home health services, 
are presented by income in 
Table 5. In 1968, medical 



256 



reimbursements per person 
enrolled In the highest group 
were $160, twice the amount 
paid to the lowest income 
group ($76). 

High income persons ap- 
peared to reap greater 
benefits from Medicare for 
most reimbursement 
measures in 1968. First, the 
number of highest income 
persons who received reim- 
bursable services per 1 ,000 
Medicare enrollees (552.3) 
was 26 percent higher than 
the number of lowest income 
persons, 438.2. Second, the 
amount of Medicare reim- 
bursement per services was 
higher for high income per- 
sons, $10.40, compared with 
low income persons, $6.06. 
Third, Medicare reimburse- 
ments per enrolled person 
were twice as high for the 
highest income group than 
for the lowest income group: 
$160 compared with $76. 
E. Federal and State 

Health Expenditures — 

The Poor 
In 1965, PL 89-97 was 
enacted incorporating Title 
XIX as an amendment of the 
Social Security Act. This Title 
created a program for finan- 
cial aid to the poor that was 
to be jointly funded and ad- 
ministered by the Federal 
Government and those States 
that adopted the program. 
Popularly dubbed Medicaid, 
the program had as its aim 
the achievement of a higher 
level or equity in access to 
health care services through 
financial support. But 
sometimes there are dis- 
crepancies between program 
intents and achievements. 
Has Medicaid been effective 
in reducing the financial im- 
pact of health care expen- 
ditures among the disadvan- 
taged? The discussion in this 
section draws on data per- 
taining only to persons 
enrolled in the program, and 
therefore identifies only en- 



Figure 7 

Use of all services by the aged, reimbursement per person served: ratio of 
white to nonwhite, 1967-1976. 



Ratio: White to 
Non-White Races 



1.20 



1.10 



1.00 



.90 



1967 



1968 



1969 



1971 



1973 



1974 



1975 



1976 



Source: "Equal Treatment and Unequal Benefits: A Re-examination of the Use of 
Medicare Services by Race, 1967-1976," Ruther, M. and Dobson, A. In Health Care 
Financing Review, Winter, 1981. 



Figure 8 

Physician and other medical services under Medicare, reimbursement per 
person served: ratio of white to nonwhite, 1967-1976. 

Ratio: White to 
Non-White Races 



1.30 



1.20 



1.10 



1.00 



1967 



1968 



1969 



1971 



1973 



1974 



1975 



1976 



Source: "Equal Treatment and Unequal Benefits: A Re-examination of the Use of 
Medicare Services by Race, 1967-1976," Ruther, M. and Dobson, A. In Health Care 
Financing Review, Winter, 1981. 



dogenous inequities. Quick 
mention is made, however, of 
exogenous inequities which 
stem directly from the pro- 
gram. For instance, there are 
inequities associated with 
eligibility for Medicaid. 

In 1980 there were 193.2 
million individuals not 
covered by Medicaid for any 
portion of the year. Of these 
uncovered individuals, 28.2 
percent had family incomes 
between 0 and 200 percent 
of the official poverty level. 
This amounts to 54.5 million 
needy persons who are not 
covered. Some of these 
people may either not fall into 
a category appropriate for 
Medicaid eligibility (aged, 
blind, disabled, or members 
of families with dependent 
children) or have incomes 
above the income levels for 
Medicaid eligibility. Twenty- 
nine states have a Medicaid 
cutoff limit that is less than 50 
percent of the Federal 
poverty level. Some of the 
needy may be in States 
without programs for the 
medically needy, or have ex- 
penses that are large, but not 
sufficient to reduce income to 
the medically needy level 
(18). 

"In any case, almost all 
persons in the United States 
who experience 'catastrophic' 
out-of-pocket health expenses 
above 15 percent of family 
income have incomes below 
200 percent of the official 
poverty level. Some of these 
do ultimately receive 
Medicaid coverage after 
spending a relatively high 
proportion of income on 
health expenses" (18, p. 48). 
Actually, 30.7 percent of the 
persons who paid more than 
15 percent of family income 
for health care were in the 
lowest poverty level grouping 
(0-55 percent). For the entire 
needy group (0 to 100 per- 
cent of poverty level group), 
the proportion of those pay- 



257 



ing more than 15 percent of 
family income for health care 
was less than 1 percent. 

Table 6 again makes the 
point that many poor people 
are not covered by Medicaid. 
Although in 1980 13 percent 
of the U.S. population lived in 
families with incomes below 
the poverty line, Medicaid 
coverage was provided to 
only 9.7 percent of the 
population. The situation was 
actually worse than this com- 
parison shows, since over 41 
percent of the persons with 
Medicaid coverage lived in 
families with incomes above 
the poverty line (19). 

The racial/ethnic data in 
Table 2 suggests that black 
poor are more completely 
covered by Medicaid than 
are white poor. However, 
judgments about equity must 
take into consideration any 
differences in the health of 
black poor versus white poor. 
F. Federal and State 

Health Expenditures — 

The Young 
As noted elsewhere in this 
book, two segments of the 
age distribution of our 
population are particularly at 
risk with respect to morbidity: 
the young and the aged. The 
aged have been discussed 
previously in the context of 
both the Medicare and the 
Medicaid programs. The 
young have potential access 
only to the Medicaid 
program. 

In 1983, the noted health 
economist Karen Davis told a 
congressional subcommittee 
that Medicaid coverage for 
children is declining at a time 
when the number of children 
living in poverty is increasing. 
While the percentage of U.S. 
children living in poverty in- 
creased from 15 to 20 per- 



cent, the Medicaid coverage 
significantly decreased. "In 
1979, 10.5 million poor 
children were covered by 
Medicaid. Two years later (in 
1980), that number has 
shrunk to 9 million children. 
The 1982 numbers show a 
drop to 8 million. Nearly 6 
million children in families 
with incomes below the 
poverty level are without 
Medicaid coverage. Less 
than 40 percent of children in 
poverty are covered by 
Medicaid. Of these uninsured 
poor children, two million live 
in families with incomes 
below 50 percent of the 
poverty level." (20). 

Davis explained that this is 
because, "Currently, 30 
states do not offer Medicaid 
coverage to children in intact 
families, even though their 
family income is low enough 
to qualify for welfare aid. 
Moreover, no state provides 
coverage for individuals up to 
the poverty level. In 29 
states, the income cutoff limit 
for Medicaid is less than 50 
percent of the federal poverty 
level" (20). She urged 
passage of a Federal bill to 
upgrade the coverage of 
children and poor pregnant 
women. 



258 



Table 1 

Percent of total health care expenditures covered by third party payments. 1960 to 1981 



1960 1965 1970 1975 1977 1978 1979 1980 1981 

45.1 48.2 60.1 66.6 67.2 67.5 67.3 67.1 67.9 

Source: U.S. Bureau of the Census, Statistical Abstract of the United States 1982-83 (103d edition) Washington, DC, 1982 

Table 2 

Number of Medicaid enrollees and percent distribution of sociodemographic characteristics by ethnicity and race: United States, 1980. 



Ethnicity and Race 





i oiai 


Percent of 






Non-Hispanic 




Sociodemographic characteristics 


persons 


total 


Hispanic 


White 


Black 


Other 


Total Medicaid 


21,209.9 


100.0 


2,625.1 


11,006.0 


6,942.1 


636.8 


A r-i cs 














Under 6 years 


3,833.7 


18.1 


24.0 


15.4 


19.7 


22.8 


6-21 years 


8,392.8 


39.6 


39.4 


35.4 


46.3 


38.6 


22-44 years 


3,912.6 


18.5 


16.1 


20.8 


15.9 


14.4 


45-64 years 


1,995.9 


9.4 


10.1 


9.3 


9.1 


11.7 


65 and over 


3,074.9 


14.5 


10.4 


19.1 


9.0 


12.5 


Sex 














Male 


8,435.0 


39.8 


39.3 


41.9 


35.8 


47.9 


Female 


12,774.9 


60.2 


60.7 


58.1 


64.2 


52.1 


Marital Status 














Under 17 years 


10,115.4 


47.7 


55.3 


41.8 


53.8 


50.7 


Married 


2,913.5 


13.7 


15.0 


16.9 


7.1 


27.3 


Widowed 


2,048.3 


9.7 


6.8 


11.3 


8.6 


4.8 


Separated 


1,029.0 


4.9 


6.3 


4.7 


4.8 


2.1 


Divorced 


1,654.7 


7.8 


4.7 


9.9 


6.0 


3.9 


Never married 


3,381.5 


15.9 


11.9 


14.9 


19.6 


11.3 


Unknown 


67.6 


0.3 


0.0 


0.6 


0.0 


0.0 


Poverty Level 














0-100% 


11,052.1 


52.1 


38.2 


45.2 


68.8 


47.1 


101-150% 


3,914.8 


18.5 


28.6 


20.9 


11.7 


9.3 


Greater than 150% 


6,243.0 


29 4 


33.2 


33.9 


19.5 


43.6 



Note: Numbers of persons are expressed as person years 

Source: Unpublished draft for the Health Care Financing Administration, September 30, 1983. O'Brien. M.D , Rodgers, J., and 
Baugh, D.: Ethnic and racial patterns in enrollment, health status, and health services utilization in the Medicaid population 



259 



Table 3 

Mean per capita total charges and mean per capita out-of-pocket 
expenses of the elderly, by poverty level, 1980. 



Poverty 


Mean Total 


Mean Out-of- 




Level 


Charges 


Pocket Expenses 


Percentage 


0-55% 


752.48 


181.66 


24 


56-75% 


2499.94 


243.09 


10 


76-100% 


1928.73 


260.63 


14 


101-150% 


1657.73 


319.13 


19 


151-200% 


1824.53 


391.85 


21 


200% 


1757.25 


345.68 


20 



Source: Unpublished draft, Deliverable No 305F, Health Care Financing Administra- 
tion, February 28, 1983. Howell, E., Corder, L, and Dobson, A.: Out-of-pocket health 
expenses for Medicaid and other poor and near poor persons in 1980 



Table 4 

Mean per capita total charges and mean per capita out-of-pocket 
expenses of racial/ethnic groups, elderly and nonelderly, 1980. 



Racial/Ethnic Mean Total Mean Out-of- 

Group Charges Pocket 

Expenses Percentage 



Age Under 65 








White 


619.07 


186.51 


30 


Black 


502.61 


124.77 


25 


Non-Hispanic 


613.91 


181.55 


30 


Hispanic 


470.29 


149.90 


32 


Age 65 and Over 








White 


1800.44 


341.99 


1 9 


Black 


1354.47 


188.36 


14 


Non-Hispanic 


1762.61 


331.64 


19 


Hispanic 


1642.44 


145.83 


9 


Total Persons 








White 


754.52 


204.34 


27 


Black 


569.78 


129.78 


23 


Non-Hispanic 


745.27 


198.71 


27 


Hispanic 


517.88 


149.74 


29 



Source: Unpublished draft. Deliverable No 305F, Health Care Financing Administra- 
tion, February 28, 1983. Howell, E , Corder, L, and Dobson, A. Out-of-pocket health 
expenses for Medicaid and other poor and near poor persons in 1980 



260 



Table 5 

Medicare reimbursements for covered services under the supplementary medical insurance program and persons served, by income, 1968. 1 



Supplementary medical insurance services 





I otal 


Under 
$2,000 


$2,000- 
4,999 


$5,000- 
9,999 


$10,000- 
14,999 


$15,000 
and over 


Ratio, highest 
income to lowest 
income 


Persons receiving reimbursable 
services per 100 Medicare 
enrollees 


460.1 


438.2 


425.9 


475.0 


527.2 


522.3 


1.26 


Number of reimbursable services 
per person receiving reimbursable 
services 


26.6 


28.7 


23.4 


26.6 


27.5 


27.9 


.97 


Medicare reimbursement per 
reimbursable service 


$7.27 


$6.06 


$8.1 1 


$8.21 


$7.95 


$10.40 


1.72 


Medicare reimbursement per 
person enrolled 


$88.60 


$76.32 


$80.95 


$103.87 


$115.10 


$160.30 


2.10 



'Including unknown income 

Source: 1) U.S. Department of Health, Education and Welfare, Social Security Administration, Office of Research and Statistics. 
(Calculated from unpublished tabulations from the 1968 Current Medical Survey.) 2) Financing Medical Care: Implications for Ac- 
cess to Primary Care: Where Medicine Fails, Amdreopoulas, S. (ed ). John Wiley and Sons, New York, 1974 



Table 6 



Percent of racial/ethnic groups covered by Medicaid compared with 


percent of racial/ethnic poor, 1980. 




Racial/Ethnic 


Percent of Group 


Percent of Group 


Group 


Covered by Medicaid 


Below Poverty Level 


White 


6.3 


10.2 


Black 


27.6 


32.5 


Hispanic 


17.9 


25.3 


Total U.S. 


9.7 


13.0 



Source: Compiled and abstracted by CHESS from 1) Unpublished draft, Deliverable 
No. 305F, Health Care Financing Administration, September 30. 1983. O'Brien, M. 
K., Rodgers, J., and Baugh, D.: Ethnic and racial patterns in enrollment, health status, 
and health services utilization in the Medicaid population 2) U.S. Bureau of the Cen- 
sus, Statistical Abstract of the United States: 1982-83 (103d edition). Washington, DC, 
1982. 



261 



References 

1. Gibson, R.M.: National 
Health Expenditures. 1981. 
Health Care Financing 
Review, RCFA Pub. No. 
03146. U.S. Government 
Printing Office, Washington, 
DC, September 1982. 

2. U.S. Department of Com- 
merce. Bureau of the Cen- 
sus: USA Statistics in brief: a 
statistical abstract supple- 
ment, 1982-1983. 

3. Weichert, Barbara G.: 
Health care expenditures. 
Health, United States, 1981. 
U.S. DHHS, Public Health 
Service. National Center for 
Health Statistics. DHHS 
Publication No. 82-1232, U.S. 
Government Printing Office, 
Washington, DC, 1982. 

4. U.S. DHEW. Public Health 
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Health Statistics: Health in the 
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DHEW Publication No. 
80-1233, U.S. Government 
Printing Office, Washington, 
DC, 1980. 

5. Meyers, Samuel M.: 
Growth in health maintenance 
organizations. Health, United 
States, 1981, U.S. DHHS 
Publication No. 82-1232, U.S. 
Government Printing Office, 
Washington, DC, 1982. 

6. National Center for Health 
Services Research: Man- 
datory rate setting effectively 
holds down hospital costs. 
NCHSR Research Activities, 
July 1983, No. 53. 

7. National Center for Health 
Statistics. M Dicker, Health 
care coverage and insurance 
premiums for families. United 
States, 1980. National 
Medical Care Utilization and 
Expenditure Survey. 
Preliminary Data Report No. 
3. H. DHHS Pub. No. 
83-20000. Public Health 
Service, Washington. U.S. 
Government Printing Office, 
Washington, DC, May 1983. 

8. Weichert, Barbara G.: 
Health care expenditures. 
Health United States, 1981. 



U.S. DHHS. Publication 
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Center for Health Statistics. 
DHHS Publication No. 
82-1232. U.S. Government 
Printing Office, Washington, 
DC, 1982. 

9. Cafferats, G.L: Private 
health insurance: premium 
expenditures and sources of 
payment. Data Preview 17. 
National Health Care 
Research. DHHS Publication 
No. 84-8364. November 
1983. 

10. U.S. Department of Com- 
merce, Bureau of the Cen- 
sus: Statistical Abstract of the 
United States, 103d Edition. 
1982-83. 

11. O'Brien, M.D., Rodgers, 
J., and Baugh, D.: Ethnic 
and racial patterns in enroll- 
ment, health status, and 
health services utilization in 
the Medicaid population. Un- 
published draft for the Health 
Financing Administration. 
September 30, 1983. 

12. Howell, E., Corder, L, 
and Dobson, A.: Out-of- 
pocket health expenses for 
Medicaid and other poor and 
near poor persons in 1980. 
Unpublished draft. Deliver- 
able No. BUSF, Health Care 
Financing Administration, 
February 28, 1983. 

13. Hodgson, Thomas A, 
and Kopstein, Andrea N.: 
Health care expenditures for 
major diseases. Health, 
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14. HEW, Social Security Ad- 
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List of Tables 

1 . Percent of total health 
care expenditures covered 
by third party payments. 
1960 to 1981. 

2. Number of Medicaid 
enrollees and percent 
distribution of 
sociodemographic 
characteristics by ethnicity 
and race: United States, 
1980. 

3. Mean per capita total 
charges and mean per capita 
out-of-pocket expenses of the 
elderly, by poverty level, 
1980. 

4. Mean per capita total 
charges and mean per capita 
out-of-pocket expenses of 
racial/ethnic groups, elderly 
and nonelderly, 1980. 

5. Medicare reimbursements 
for covered services under 
the supplementary medical 
insurance program and per- 
sons served, by income, 
1968. 

6. Percent of racial/ethnic 
groups covered by Medicaid 
compared with percent of 
racial/ethnic poor, 1980. 



262 



List of Figures 

1 . National health expen- 
ditures: 1960 to 1981. 

2. Mean per capita out-of- 
pocket expenses of the 
elderly, by poverty level, 
1980. 

3. Medicare reimbursement 
for physician services, by 
race, 1976. 

4. Medicare reimbursements 
for inpatient services, by 
race. 1976. 

5. Medicare reimbursements 
for hospital outpatient 
services, by race, 1976. 

6. Use of all services by the 
aged, reimbursement per 
enrollee: ratio of white to non- 
white, 1967-1976. 

7. Use of all services by the 
aged, reimbursement per 
person served: ratio of white 
to nonwhite, 1967-1976. 

8. Physician and other 
medical services under 
Medicare, reimbursement per 
person served: ratio of white 
to nonwhite, 1967-1976. 



! 



BHPr 

U S DEPARTMENT OF 
HEALTH & HUMAN SERVICES 
Public Health Service 

Health Resources and Services Administrator! 
Bureau of Health Professions 

DHHS Publication No (HRSA) HRS-P-DV 85-1